Medical Appeals & Grievance, RN Specialist II

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

📋 Description

• Conduct thorough analysis, clinical assessments, and resolution of provider appeals, inquiries, corrected claims, subscriber reconsiderations, member appeals, and provider grievances.

• Identify, investigate, process, resolve, and respond to customer inquiries through both written and verbal communication.

• Manage daily responses to a high volume of health insurance appeal correspondence.

• Evaluate medical records and apply criteria for medical necessity as well as benefit plan requirements.

• Ensure the maintenance of complete and accurate records.

• Meet the quality, quantity, productivity, accuracy, and timeliness standards mandated by departmental, regulatory, and accreditation guidelines.

• Collaborate and consult with internal departments, external plans, providers, businesses, and government agencies.

• Attend departmental and interdepartmental meetings.

• Engage in ongoing education and advancements in medicine and managed care.

• Process level-one appeals, grievances, and corrected claims utilizing benefit booklets, policies, medical criteria, claims research, contracts, fee schedules, and related documents.

• Clarify contract benefits, coverage modifications, eligibility, claims, programs, and provider networks to customers.

• At advanced levels, manage FEP, Blue Card Home, and Blue Card Host cases; handle all tiers of MAG cases; lead meetings; oversee projects; create policies, procedures, and job aids; train staff; assign cases; prepare reports; analyze trends; implement process improvements and educational sessions; and provide leadership within the department.

⛳️ Requirements

• Associate’s Degree in a healthcare-related field or a Nursing Diploma.

• Active, current, and unrestricted Registered Nurse (RN) license to practice in Arizona or a compact state.

• Level 1: Minimum of 1 year of experience in clinical and health insurance or a related healthcare field.

• Level 2: Minimum of 3 years of experience in clinical and health insurance or a related healthcare field, plus 1 year of managed care experience.

• Level 3: Minimum of 5 years of experience in clinical and health insurance or a related healthcare field, plus 2 years of managed care experience.

• Level 4: Minimum of 8 years of experience in clinical and health insurance or a related healthcare field, plus 3 years of managed care experience with above-satisfactory performance in managed care.

• Intermediate proficiency in PC applications.

• Intermediate skills in using office equipment, including copiers, fax machines, scanners, and telephones.

• Ability to maintain confidentiality and privacy.

• Advanced clinical knowledge.

• Strong interpersonal and active listening skills.

• Competence in composing business correspondence.

• Ability to interpret and clarify policies, procedures, programs, and guidelines.

• Strong investigative and analytical research skills.

• Proficiency in navigating, gathering, inputting, and maintaining data across multiple systems.

• Ability to follow and accept instructions and direction.

• Capacity to foster collaborative working relationships.

• Strong organizational and prioritization skills, especially under time constraints.

• Independent judgment and problem-solving abilities.

• For Levels 3 and 4: capability to assist with training and to revise or develop departmental policies, procedures, and desk levels.

• Preferred knowledge of CPT, ICD-9, ICD-10, HCPCS, and DRG coding.

• Preferred familiarity with McKesson InterQual criteria and medical coverage guidelines/policies.

• Preferred advanced ability to interpret contract language and benefits.

🏝️ Benefits

• Opportunity for remote work with no onsite expectation.

• Full-time work schedule of at least 40 hours per week.

• Participation in continuing education programs.

• Annual involvement in community service initiatives and projects, including CARES Club, United Way, and community wellness programs.