RN Appeals & Quality Care Coordinator

MJHS; New York (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Elderplan in New York, NY is seeking an RN Coordinator to investigate and respond to clinical appeals, expedited grievances, and potential quality of care concerns in accordance with CMS and DOH regulations.

The ideal candidate is a licensed New York nurse (BSN preferred) with 2+ years in managed care or hospital-based utilization/case management, plus strong communication and multitasking skills to support member services and quality improvement initiatives.

Qualifications

• Graduate of accredited nursing program; BSN preferred.
• 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

• The RN Coordinator will investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for Medicare & Medicaid Services), and DOH regulations.

Education

BSN preferred

Licensed nurse in New York State

Job description

Elderplan in New York, NY is seeking an RN Coordinator to investigate and respond to clinical appeals, expedited grievances, and potential quality of care concerns in accordance with CMS and DOH regulations.

The ideal candidate is a licensed New York nurse (BSN preferred) with 2+ years in managed care or hospital-based utilization/case management, plus strong communication and multitasking skills to support member services and quality improvement initiatives.