Registered Nurse

Actalent; Mather (CA); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company is seeking a Commercial Appeals and Grievance Registered Nurse (RN) to review and process member-generated appeals. The role involves ensuring compliance with medical necessity and coding accuracy while collaborating with medical professionals. This fully remote position offers competitive pay and various benefits.

Benefits

401(k) Retirement Plan

Life Insurance

Short and long-term disability

Health Spending Account (HSA)

Employee Assistance Program

Time Off / Leave

Qualifications

• 1 year of Utilization Review / Management experience.
• 2+ years of Managed Care experience.
• 2 years minimum of Acute or Sub-Acute Clinical Experience.

Responsibilities

• Review and process member-generated appeals and grievances.
• Ensure accurate and timely first-level reviews according to standards.
• Collaborate with medical directors and leadership for final determinations.

Skills

Utilization Management

Utilization Review

Medical Policy Compliance

Coding Accuracy

Collaboration

Education

CA RN License

Associate Degree of Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Microsoft Office

Job description

The Commercial Appeals and Grievance Registered Nurse (RN) reviews and processes appeals resulting from member-generated pre-service or post-service concerns or complaints. The RN is responsible for reviewing 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 National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG. The RN reviews appeals for benefits, medical necessity, coding accuracy, and medical policy compliance. Collaboration with medical directors, coordinators, and leadership is essential to review, process, and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure members have quality access to provider care.

Responsibilities

• Review and process member-generated appeals and grievances.
• Ensure accurate and timely first-level reviews according to company and regulatory standards.
• Utilize NCD, LCD, Milliman Care guidelines, and other recognized sources for review.
• Assess appeals for benefits, medical necessity, coding accuracy, and policy compliance.
• Collaborate with medical directors, coordinators, and leadership to provide final determinations.
• Communicate clear rationales and necessary follow-up actions to ensure quality care access.
• 1 year of Utilization Review / Management experience
• Proficiency in Utilization Management and Utilization Review
• Knowledge of MCG and prior authorization processes
• Experience in acute and inpatient settings
• Proficiency in Microsoft Office

Additional Skills & Qualifications

• CA RN License
• 2+ years of Managed Care experience
• 2 years minimum of Acute or Sub-Acute Clinical Experience
• Associate Degree of Nursing (ADN) preferred
• Bachelor of Science in Nursing (BSN) preferred

This is a remote position with a work schedule from Monday to Friday, 8 : 30 am to 5 : 00 pm.

Pay and Benefits

The pay range for this position is $45.00 - $55.00 / hr.

Eligibility requirements apply to some benefits and may depend on your job

classification and length of employment. Benefits are subject to change and may be

subject to specific elections, plan, or program terms. If eligible, the benefits

available for this temporary role may include the following :

• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Employee Assistance Program
• Time Off / Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on May 24, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [emailprotected] for other accommodation options.