RN Appeals & Managed Care Quality Coordinator

Metropolitan Jewish Health System, Inc.; New York, Northern (NY, KY); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Metropolitan Jewish Health System, Inc. is seeking an RN Coordinator to investigate and respond to clinical appeals and grievances from members and providers in line with Elderplan, CMS, and DOH regulations.

The candidate should be a graduate of an accredited nursing program with NYS licensure, 2 years in managed care or hospital-based utilization/case management, plus strong communication and evidence-based practice research skills to resolve issues effectively.

Qualifications

• 2 years managed care or hospital-based utilization/case management experience
• 2 years minimum clinical experience
• Licensed nurse in New York State
• Proficiency with Microsoft Word, Excel, Power Point and Outlook is required
• Must have excellent written and verbal communication skills
• Must be comfortable researching current evidence based practice guidelines and protocols
• Must be able to multi-task and manage multiple projects efficiently, meet deadlines, demonstrate analytical/critical thinking skills, and provide excellent customer services that leads to positive problem resolution

Responsibilities

• Investigation and response to written and/or verbal clinical appeals
• Expedited clinical grievances and potential quality of care grievances
• Ensure compliance with Elderplan Contract Benefits, CMS, and DOH regulations

Skills

Communication skills

Critical thinking

Education

Graduate of accredited nursing program

BSN preferred

Tools

Microsoft Word

Excel

PowerPoint

Outlook

Job description

Metropolitan Jewish Health System, Inc. is seeking an RN Coordinator to investigate and respond to clinical appeals and grievances from members and providers in line with Elderplan, CMS, and DOH regulations.

The candidate should be a graduate of an accredited nursing program with NYS licensure, 2 years in managed care or hospital-based utilization/case management, plus strong communication and evidence-based practice research skills to resolve issues effectively.