Appeals & Grievance Nurse Analyst

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Review and process appeals from members and providers.

• Ensure resolutions are timely and accurate, adhering to CMS, Medicare, and TennCare guidelines.

• Assess cases, identify next steps, and manage multiple priorities within strict deadlines.

• Examine clinical and medical records, summarizing findings for the Medical Director's review.

• Investigate and document the substance and validity of appeals or quality-of-care grievances using various systems.

• Evaluate documentation of medical necessity, including complex scenarios.

• Conduct outreach for clinical information as necessary.

• Prepare case files for the Medical Director's review.

• Draft personalized appeal and quality-of-care grievance response letters tailored to members and providers.

• Review response letters for accuracy and compliance, suggesting improvements as needed.

• Collaborate with both clinical and non-clinical staff to resolve appeals and quality-of-care issues.

• Meet turnaround times that can be as short as 24–72 hours.

⛳️ Requirements

• A minimum of 3 years of clinical nursing experience is required.

• Must be a Registered Nurse (RN) with an active license in Tennessee, or hold an active license in the state of residence if participating in the Nurse Licensure Compact Law.

• Familiarity with Medicare, CMS, and TennCare regulations.

• Experience with appeals and grievance procedures.

• Strong clinical knowledge.

• Excellent analytical skills and attention to detail.

• A customer-focused approach.

• Proficient in case management.

• Accurate data entry skills.

• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint).

• Ability to work independently with minimal supervision or within a team setting.

• Capability to manage multiple projects simultaneously.

• Outstanding oral and written communication abilities.

• Strong interpersonal and organizational skills.

• Willingness to work a 40-hour week with flexibility for potential weekend coverage.

• Sponsorship is not available for this position.

🏝️ Benefits

• Fully remote position.

• Standard 40-hour workweek.

• Flexibility based on business requirements.

• Potential for weekend coverage.

• Access to AI-enabled tools and established workflows, templates, and policies to support daily tasks.