Registered Nurse 4

Aditi Consulting; Long Beach (CA); On-site; USD 66,124 - 68,880; Full time

Benefits offered by this job

401(k) plan participation

Paid days off

Medical, dental, and vision benefits

Job summary

Aditi Consulting seeks a Commercial Appeals and Grievance RN to handle member-generated appeals related to healthcare services. The role involves reviewing medical records, ensuring compliance with regulations, and collaborating with healthcare professionals. The ideal candidate will have strong clinical skills and experience in managed care, offering competitive pay and benefits.

Qualifications

• Experience in Managed Care (2 years minimum).
• Acute or Sub-Acute Clinical Experience (2 years minimum).
• Knowledge of regulatory requirements and clinical documentation.

Responsibilities

• Review and process member-generated appeals.
• Collaborate with medical directors on clinical appeals.
• Ensure compliance with medical necessity and coding accuracy.

Skills

Managed Care Experience

Strong communication skills

Clinical assessment skills

Education

Associate Degree of Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Excel

Microsoft

PDF

TEAMS

Share-Point

Job description

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This range is provided by Aditi Consulting. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$48.00/hr - $50.00/hr

Payrate: $48.00 - $50.00/hr.

Summary:
The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint. The Commercial Appeals and Grievance RN will report directly to the Nurse Manager and be responsible for reviewing all medical records and documentation concurrently while processing these member-generated appeals. In this role, the RN will perform accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines and other nationally recognized sources such as NCCN and ACOG. The Appeals and Grievance RN will review appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role the Appeals and Grievance RN will collaborate with medical directors, coordinators and leadership to review, process and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure our members are provided with quality access to provider care.

Skills:

• Managed Care Experience (MCG, LCD and NCD knowledge)- 2 years minimum
• Acute or Sub-Acute Clinical Experience - 2 years minimum
• Ability to work in a fast paced and changing environment, strong communication skills, ability to work independently and in a team setting, strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.

Nice to Have:

• Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews. Previous experience with prior authorization, pre-service and post-service review.
• Strong Understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS).

Software Skills:

• Excel, Microsoft, PDF, Shared-Drive, TEAMS, Share-Point

Education/Experience:

• Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred

Pay Transparency: The typical base pay for this role across the U.S. is: $48.00 - $50.00/hr. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience and the benefits package you select. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, 10 paid days off, 401(k) plan participation, commuter benefits and life and disability insurance.

For information about our collection, use, and disclosure of applicant's personal information as well as applicants' rights over their personal information, please see our Privacy Policy (https://www.aditiconsulting.com/privacy policy).

Aditi Consulting LLC uses AI technology to engage candidates during the sourcing process. AI technology is used to gather data only and does not replace human based decision making in employment decisions. By applying for this position, you agree to Aditi’s use of AI technology, including calls from an AI Voice Recruiter.

#AditiConsulting

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Contract

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

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