RN Appeals and Grievances / Quality of Care

Key Job Details:

• Position: RN Appeals And Grievances / Quality Of Care
• Company: Workwarp
• Compensation: a competitive salary
• Location: Remote
• Start Date: Immediate openings available

 

 

Active California Nursing License is required. Compact License not accepted... Multistate License not accepted. Duties • The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review. • Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan. • Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation. • Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director. • Perform other duties as assigned. Required: 2 or more years of experience in Clinical Nursing and 2 years in MediCaid in a managed care/ health plan environment. 2 or more years of experience in Clinical Nursing and 2 years in MediCare in a managed care/ health plan environment. Good working knowledge of regulatory requirements/standards. Excellent interpersonal and communication skills. Computer literacy and adaptability to computer learning. Time management and priority setting skills. Must be organized and a team player Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies. Schedule: There are 4 schedules available, holidays will be required if they fall on your schedule: Wednesday - Sunday: 7am-4pm Pacific Time • Off days: Monday - Tuesday Sunday - Thursday: 7am-4pm Pacific Time • Off days: Friday - Saturday Tuesday - Saturday: 7am-4pm Pacific Time • Off days: Sunday - Monday Monday - Friday: 8am - 5pm Pacific Time • Off Days: Saturday - Sunday Licenses/Certifications Required • Registered Nurse (RN) - Active, current and unrestricted California Nursing License Job Types: Full-time, Contract Pay: From $45.00 per hour Expected hours: 40 per week Schedule: • Holidays Application Question(s): • Do you have managed care experience within a health plan? • Do you current have an active California Nursing License? • Do you have 2 years experience with MediCaid and MediCare? Work Location: Remote Apply Job! For more such jobs please click here!

 

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