Registered Nurse - Appeals and Grievances REMOTE in CA

Remote role Full-time Open position

Position: Registered Nurse - Appeals and Grievances

Relocation Expenses/ Assistance: NO

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.

Registered Nurse (RN) of California
Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred
Excel, Microsoft, PDF, Shared-Drive, TEAMS, Share-Point
Managed Care Experience (MCG, LCD and NCD knowledge)– 2 years minimum
Acute or Sub-Acute Clinical Experience – 2 years minimum
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).
Strong Skills with Excel, Microsoft, PDF, Shared drive, medical records review,
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.

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