RN Lead, Medicare Appeals & Grievances

Wollborg Michelson Personnel Service Inc; Oakland (CA); On-site; USD 120,000 - 160,000; Full time

Job summary

Wollborg Michelson Recruiting in Oakland, CA seeks an RN Lead for Medicare Appeals and Grievances. The role reports to the Appeals and Grievances Manager and leads first-level appeal reviews for medical necessity, coding accuracy, policy compliance, and contract requirements.

Responsibilities include overseeing daily team activities, conducting training, and presenting cases to the Medical Director, while ensuring compliance with state and federal regulations and professional licensure standards.

Qualifications

• RN license in good standing.
• Knowledge of Nurse Practice Act and regulatory implications.

Responsibilities

• Review cases for medical necessity, coding accuracy, and policy compliance.
• Prepare and present appeal and grievance cases to Medical Director.
• Communicate determinations to providers and members.
• Manage daily team activities and quality reviews.
• Lead training, supervise staff, and drive process improvements.
• Stay current with applicable regulations and licensure requirements.
• Act as SME for quality-of-care concerns and clinical judgments.

Skills

Verbal communication

Attention to detail

Problem solving

Clinical judgment

Team leadership

Priority management

Process improvement

Education

Associate degree in nursing

Bachelor's degree preferred

Job description

Wollborg Michelson Recruiting in Oakland, CA seeks an RN Lead for Medicare Appeals and Grievances. The role reports to the Appeals and Grievances Manager and leads first-level appeal reviews for medical necessity, coding accuracy, policy compliance, and contract requirements.

Responsibilities include overseeing daily team activities, conducting training, and presenting cases to the Medical Director, while ensuring compliance with state and federal regulations and professional licensure standards.