Nurse RN 4

TALENT Software Services; California (MO); On-site; USD 68,000 - 72,000; Full time

Job summary

A leading company in IT Services seeks a Medicare Appeals and Grievances RN for a 6-month full-time role. This position involves clinically reviewing member appeals and grievances, requiring a Bachelor's Degree in Nursing and experience in health insurance. Ideal candidates will demonstrate independence and sound clinical judgement. Competitive salary ranges from $68,000 to $72,000 annually.

Qualifications

• 2-4 years of health insurance or related experience required.
• Higher-level certifications are highly desirable.

Responsibilities

• Perform first-level appeal reviews for members utilizing NCD and LCD guidelines.
• Review for medical necessity and non-covered benefits.

Skills

Knowledge of Medicare benefits and appeal reviews

Ability to act independently using sound clinical judgement

Excellent communication skills

Education

Bachelor's Degree in Nursing

Job description

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The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that result from either a preservice, post-service, or claim denial. The Medicare Appeals and Grievances RN will report to the Appeals and Grievances Manager. In this role, you will be responsible for performing first-level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, pharmacy policies, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews may also be performed for medical necessity, non-covered benefits, and to meet the criteria for the coding billed. The ideal candidate will have previous insurance/managed care experience and hold at least a Bachelor's Degree in Nursing. Higher-level certifications are highly desirable.

Duration: 6 Months

Required Skills (top 3 non-negotiables):

1. Knowledge of Medicare benefits and appeal reviews
2. Requires 2-4 years of health insurance or related experience
3. Demonstrate the ability to act independently using sound clinical judgement

Preferred Skills (nice to have):

• Experience with pharmacy clinical reviews
• Works well in a fast-paced team environment
• Excellent communication skills

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Other

Industries

• IT Services and IT Consulting

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Santa Monica, CA $68,000.00-$72,000.00 2 weeks ago

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