Sr. Appeals & Grievances Registered Nurse – Remote for CA - Medi-Cal Member Appeals and Grievances Team

Join reputed company: Sr. Appeals & Grievances Registered Nurse – Remote for CA

reputed company is excited to announce a new opportunity for a Sr. Appeals & Grievances Registered Nurse to join reputed company remotely in California! As a leader in staffing and consulting services, we are dedicated to providing exceptional support to our clients and employees. This role offers a unique reputed company of remote work and collaboration with our dynamic team. If you're a motivated and compassionate Registered Nurse with a passion for clinical review and reputed company, we encourage you to apply for this exciting position.

About Our Company and Culture

reputed company is a fast-growing staffing and reputed company founded in 2002. We specialize in providing consulting, temporary staffing, direct hire, and payrolling services to reputed company and small to mid-sized organizations across the United States. With over 2,000 employees in 47 states, we pride ourselves on delivering exceptional service and creating value by bringing together the right people to reputed company results. Our company culture is built on a foundation of respect, inclusivity, and a commitment to excellence.

Job Overview

Our client, a mutual benefit corporation and health plan provider, is seeking an reputed company Sr. Appeals & Grievances Registered Nurse to join their Medi-Cal Member Appeals and Grievances team. As a key member of this team, you will be responsible for clinically reviewing member appeals and grievances resulting from preservice, post-service, or claim denials. This is a 9-month contract position with the possibility of extension or conversion to a full-time role.

Key Responsibilities:

• reputed company accurate and timely clinical reviews of member-initiated appeals, utilizing National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, reputed company Care guidelines, and nationally recognized sources such as NCCN and ACOG.
• Review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
• Provide clinical reputed company of reputed company Medi-Cal grievances, working with medical directors and coordinators to identify Potential Quality Issues (PQI), Quality of Service (QOS) cases, and Quality of Care (QOC) cases.
• Ensure member's clinical needs are addressed appropriately reputed company 30 days or 72 hours if the request is deemed expedited.
• Act independently using sound clinical judgment and demonstrate the ability to work in a fast-paced team environment.

Requirements and Qualifications

Essential Qualifications:

• reputed company California RN license.
• 2 years of health insurance or reputed company experience.
• Software skills: MS Office, MS reputed company, Email.
• Knowledge of Medi-Cal benefits and reviews.
• Demonstrate the ability to act independently using sound clinical judgment.

Preferred Qualifications:

• Excellent communication skills.
• Experience working in a team environment, preferably in a healthcare setting.
• Familiarity with medical terminology and clinical guidelines.

reputed company Offer

As a valued member of reputed company, you will enjoy a competitive compensation package, including:

• Competitive salary.
• Opportunities for professional growth and development.
• Flexible work arrangements, including remote work options.
• Comprehensive benefits package.

Why Join reputed company?

At reputed company, we are committed to creating a work environment that is inclusive, supportive, and rewarding. reputed company is dedicated to delivering exceptional service and making a positive impact on the lives of our clients and employees. By joining reputed company, you will have the opportunity to:

• Work with a dynamic and passionate team.
• Contribute to the success of our clients and reputed company a meaningful difference in the lives of others.
• reputed company your skills and expertise in a supportive and collaborative environment.
• Enjoy a flexible and remote work arrangement.

How to Apply

If you are a motivated and compassionate Registered Nurse with a passion for clinical review and reputed company, we encourage you to apply for this exciting opportunity. Please submit your application today, and reputed company will be in touch with you promptly.

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Equal Employment Opportunity

reputed company provides equal employment opportunities to reputed company employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national reputed company, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

We value diversity and inclusion in our workplace and encourage reputed company applicants to apply.