Registered Nurse 4

Aditi Consulting

Rancho Cordova (CA)

On-site

USD 68,880 - 71,635

Full time

14 days+

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Benefits offered by this job

Medical, dental, and vision benefits

10 paid days off

401(k) plan participation

Commuter benefits

Life and disability insurance

Job summary

Aditi Consulting is seeking a Medicare Appeals and Grievances RN to join their team. This role involves clinically reviewing member appeals and grievances, performing first level appeal reviews, and ensuring compliance with Medicare guidelines. Ideal candidates will have a nursing degree and relevant experience in health insurance.

Qualifications

2-4 years of health insurance or related experience required.
Nursing license required.
8-10 years’ experience required.

Responsibilities

Perform first level appeal reviews for members utilizing NCD and LCD guidelines.
Review for medical necessity and non-covered benefits.
Report to the Appeals and Grievances Manager.

Skills

Knowledge of Medicare benefits and appeal reviews

Ability to act independently using sound clinical judgement

Works well in a fast-paced team environment

Education

Associate’s degree in nursing

Bachelor’s degree in nursing preferred

Higher-level certifications highly desirable

Job description

1 day ago Be among the first 25 applicants

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

$50.00/hr - $52.00/hr

Payrate: $50.00 - $52.00/hr.

Summary:
The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either preservice, post service or claim denial.

Responsibilities:

The Medicare Appeals and Grievances RN will report to the Appeals and Grievances Manger.
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.

Desired Skills:

Knowledge of Medicare benefits and appeal reviews
Requires 2-4 years of health insurance or related experience
Demonstrate the ability to act independently using sound clinical judgement
Works well in a fast-paced team environment

Qualifications:

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.
Associate’s degree in nursing required. Bachelor’s degree preferred.
Nursing license required.
8-10 years’ experience required.

Pay Transparency: The typical base pay for this role across the U.S. is: $50.00 - $52.00 /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.

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Seniority level