Nurse RN 4

SPECTRAFORCE; Long Beach (CA); Remote; USD 80,000 - 110,000; Full time

Job summary

SPECTRAFORCE is seeking a Registered Nurse IV to join their team, focusing on reviewing and processing appeals related to member concerns. This remote position in California requires strong clinical and communication skills, along with a valid RN license. The role offers competitive health benefits and a supportive work environment.

Benefits

Comprehensive health benefits

401K with matching

Referral bonuses

Paid/unpaid leave

Qualifications

• Minimum 2 years of Managed Care Experience (MCG, LCD, NCD).
• Minimum 2 years of Acute or Sub-Acute Clinical Experience.
• Knowledge of Commercial and Medicare benefits preferred.

Responsibilities

• Review and process appeals for member-generated concerns.
• Collaborate with medical directors and leadership for final determinations.
• Ensure compliance with company and regulatory standards.

Skills

Managed Care Experience

Acute or Sub-Acute Clinical Experience

Strong communication skills

Clinical assessment skills

Discrepancy recognition in medical documentation

Education

Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)

Registered Nurse (RN) license for California

Tools

Excel

Microsoft Office

PDF

Shared-Drive

TEAMS

SharePoint

Job description

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Job Summary

The Commercial Appeals and Grievance RN reviews and processes appeals resulting from member-generated pre-service or post-service concerns or complaints. Reporting directly to the Nurse Manager, the RN reviews all medical records and documentation concurrently while processing these appeals. The role involves performing accurate and timely first-level reviews according to company and regulatory standards, utilizing NCD, LCD, Milliman Care guidelines, and other recognized sources such as NCCN and ACOG. The RN reviews appeals for benefits, medical necessity, coding accuracy, and policy compliance, collaborating with medical directors, coordinators, and leadership to review, process, and provide final determinations with clear rationales and follow-up actions to ensure quality access to care for members.

Position Details

• Title: Appeals and Grievance RN (Nurse RN 4)
• Location: Remote in California
• Duration: 8+ Months
• Hours: 08:30-17:00

Required Skills

• Managed Care Experience (MCG, LCD, NCD) – minimum 2 years
• Acute or Sub-Acute Clinical Experience – minimum 2 years
• Strong communication skills, ability to work independently and in teams, clinical assessment skills, and discrepancy recognition in medical documentation

Preferred Qualifications

• Knowledge of Commercial and Medicare benefits, prior authorization experience
• Understanding of regulatory requirements (NCQA, CMS, DMHC, DHCS)

Software Skills

• Excel, Microsoft Office, PDF, Shared-Drive, TEAMS, SharePoint

Education & Certifications

• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) preferred
• Registered Nurse (RN) license for California

Benefits & Additional Information

SPECTRAFORCE offers comprehensive health benefits, dental, vision, accident, critical illness, voluntary life, hospital indemnity insurances, and additional benefits like 401K with matching, referral bonuses, and paid/unpaid leave. The company is an equal opportunity employer committed to diversity and compliance with applicable laws. Reasonable accommodations are available upon request.