Grievance & Appeals Nurse

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

📋 Description

• Manage grievances, appeals, and denials related to medical necessity, including the handling of denial notification letters.

• Analyze clinical information to assess if medical necessity criteria are satisfied.

• Evaluate clinical data to determine claim payments in accordance with company policies and NCQA guidelines.

• Reverse denied claims, uphold denials, and escalate cases to the Medical Director for further evaluation.

• Detect potential quality care issues through member grievances and case reviews concerning quality concerns.

• Compile case reviews for the Medical Director when criteria are not fulfilled.

• Identify opportunities for system enhancements and address individual care issues that may impact service expectations.

• Provide feedback for corrective action plans addressing clinical and service-related events.

• Generate communications regarding appeal resolutions for members and providers.

• Initiate system authorization events for claims that have been overturned.

• Request supplementary information from providers to ensure timely resolution of appeals.

• Collect and prepare case files for Administrative Law Hearings.

• Ensure the appeals process adheres to NCQA timelines and maintain the appeals turnaround database.

• Support the Medical Director in revising, updating, or formulating policies to meet NCQA and contractual obligations.

• Serve as a liaison between providers and the organization to resolve various issues.

• Execute other assigned tasks and adhere to established policies and standards.

⛳️ Requirements

• Candidates must possess a California RN License.

• LPN or LVN with over 3 years of clinical nursing experience or RN with more than 2 years of clinical nursing experience.

• Prior experience in utilization or appeals review is preferred.

• Familiarity with InterQual criteria is advantageous.

• Current RN, LPN, or LVN license from the respective state.

• Must be licensed to practice in California.

• Availability to work during PST hours.

🏝️ Benefits

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement programs.

• Paid time off in addition to holidays.

• Flexible work options including remote, hybrid, field, or office schedules.