Registered Nurse Remote

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

Job summary

A leading company in health care services is seeking a Registered Nurse to handle appeals and grievances. This remote role requires expertise in Utilization Management and a valid CA RN License. You will collaborate with medical professionals to ensure compliance and quality care for members. The position offers a competitive hourly rate and a comprehensive benefits package.

Benefits

Medical, dental & vision

401(k) Retirement Plan

Life Insurance

Short and long-term disability

Health Spending Account (HSA)

Transportation benefits

Employee Assistance Program

Time Off/Leave (PTO, Vacation or Sick 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 company and regulatory standards.
• Collaborate with medical directors and leadership to provide final determinations.

Skills

Utilization Management

Utilization Review

Knowledge of MCG

Proficiency in Microsoft Office

Education

CA RN License

Associate Degree of Nursing (ADN) preferred

Bachelor of Science in Nursing (BSN) preferred

Job description

1 day ago Be among the first 25 applicants

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.

Job Title: Registered Nurse

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.
  
  

Essential Skills

• 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
  
  

Work Environment

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:

• Medical, dental & vision
• 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)
• Transportation benefits
• 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 30, 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 [e-mail] for other accommodation options.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Business Consulting and Services

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