Utilization Review Nurse

SPECTRAFORCE; California (MO); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading company in healthcare is seeking a Commercial Appeals and Grievance RN to review and process appeals. The RN will ensure compliance with medical policies and collaborate with various stakeholders to provide quality care access. The role requires strong clinical assessment skills and managed care experience, with a focus on member concerns. Benefits include comprehensive health coverage and a 401K plan.

Benefits

Health Benefits

Dental Insurance

Vision Insurance

401K plan with matching

Referral Bonus Program

Qualifications

• 2 years minimum Managed Care Experience (MCG, LCD, NCD knowledge).
• 2 years minimum Acute or Sub-Acute Clinical Experience.

Responsibilities

• Review and process member-generated appeals.
• Collaborate with medical directors and leadership for clinical appeals.

Skills

Communication

Clinical Assessment

Managed Care Experience

Education

Associate Degree of Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Tools

Excel

Microsoft

PDF

TEAMS

Share-Point

Job description

Direct message the job poster from SPECTRAFORCE

The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint. The Commercial Appeals and Grievance RN will report directly to the Nurse Manager and be responsible for reviewing all medical records and documentation concurrently while processing these member-generated appeals. In this role, the RN will perform accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines and other nationally recognized sources such as NCCN and ACOG. The Appeals and Grievance RN will review appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role the Appeals and Grievance RN will collaborate with medical directors, coordinators and leadership to review, process and provide a final determination for all clinical appeals with clear rationales and any follow up actions necessary to ensure our members are provided with quality access to provider care.

Education Requirement:

Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred

Software Skills Required:

Excel, Microsoft, PDF, Shared-Drive, TEAMS, Share-Point

Required Certifications**:

Registered Nurse (RN) of California

Must haves:

Managed Care Experience (MCG, LCD and NCD knowledge)– 2 years minimum

Acute or Sub-Acute Clinical Experience – 2 years minimum

Ability to work in a fast paced and changing environment, strong communication skills, ability to work independent and in a team setting, strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.

Preferred:

Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews. Previous experience with prior authorization, pre-service and post-service review.

Strong Understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS).

About Us: SPECTRAFORCE is one of the fastest-growing workforce solutions firms in the United States. As a diversity-owned business, we place human connection at the heart of everything we do, building strong relationships with both clients and candidates to fill roles successfully. Our teams in North and Central America and India serve more than 150 Fortune clients globally, leveraging custom AI technology to provide direct hire, executive search, nearshoring, offshoring, and project staffing solutions.

Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at [e-mail] if you require reasonable accommodation.

California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting [e-mail].

LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer.

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $45.00/hr.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Other

• Industries

  Hospitals and Health Care and Hospitals

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401(k)

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