RN - Managed Care Appeals & Grievances

Clearlink Partners; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Clearlink Partners is seeking an experienced Registered Nurse to support case reviews and denial processes within managed care settings. You will review clinical information, prepare case summaries for medical director review, and ensure compliance with state and federal turnaround times.

The role emphasizes utilization management, patient education, and advocacy for cost-effective, quality care across Medicare/Medicaid programs.

Qualifications

• Minimum 5+ years of acute clinical experience.
• Minimum 2 years in a managed care environment across lines of business.
• 2+ years of appeals and grievances in managed care.

Responsibilities

• Review cases per state and federal guidelines within turnaround times.
• Ensure all clinical information is available for full review.
• Prepare claims and case summaries for MD review.
• Assist with denial overturns and utilization management.
• Provide outstanding customer service to internal and external stakeholders.
• Work across the health care spectrum to improve quality and access.

Skills

Clinical reasoning

Communication skills

Documentation & recordkeeping

Teamwork

Problem solving

Education

Registered Nurse license (PA or NJ)

Tools

Microsoft Office

Job description

Clearlink Partners is seeking an experienced Registered Nurse to support case reviews and denial processes within managed care settings. You will review clinical information, prepare case summaries for medical director review, and ensure compliance with state and federal turnaround times.

The role emphasizes utilization management, patient education, and advocacy for cost-effective, quality care across Medicare/Medicaid programs.