Registered Nurse - Appeals and Grievances **REMOTE in CA**

Amerit Consulting; California (MO); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse for Appeals and Grievances. This remote role involves reviewing and processing appeals, ensuring compliance with regulatory standards, and collaborating with healthcare professionals to provide quality care access. The ideal candidate will possess strong clinical assessment skills and experience in managed care. Join a dynamic team where your contributions will directly impact patient care and satisfaction. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Qualifications

• Registered Nurse (RN) license in California required.
• 2+ years of Managed Care and Clinical Experience necessary.

Responsibilities

• Review and process member-generated appeals and grievances.
• Collaborate with medical directors for final determination on clinical appeals.

Skills

Clinical Assessment Skills

Strong Communication Skills

Ability to Work Independently

Ability to Work in a Team Setting

Regulatory Knowledge (NCQA, CMS)

Education

Associate Degree of Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

NCD Guidelines

LCD Guidelines

Milliman Care Guidelines

Job description

Registered Nurse - Appeals and Grievances REMOTE in CA

Position: Registered Nurse - Appeals and Grievances

Location: REMOTE in CA

Duration: 6+ Months Contract with possible extension

Pay Rate: $55/hr - $60/hr (depending on experience)

Relocation Expenses/ Assistance: NO

Schedule: M-F: 8:30a – 5:00p pacific

Job Description:

• The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint.
• The 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, 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 will review appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
• The 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.

Job Requirements:

• Registered Nurse (RN) of California
• Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred
• Managed Care Experience (MCG, LCD, and NCD knowledge) – 2 years minimum
• Acute or Sub-Acute Clinical Experience – 2 years minimum
• 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).
• 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.

Seniority level

Mid-Senior level

Employment type

Contract

Job function

Health Care Provider

Industries

Hospitals and Health Care and Insurance