Appeals & Grievance Registered Nurse (RN) * Remote for CA Residents *

Overview: Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Appeals and Grievance Registered Nurse (RN).

Candidate must be authorized to work in USA without requiring sponsorship

* • *************************************************************** • ** Location: 100% Remote for California Residents

• ** Duration: Through the end of year 12/26/2025 w/ possibility of extensions or conversion to FTE role

Notes: Schedule: Monday–Friday, 08:00 AM – 05:00 PM. Description:

• The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint.
• The Commercial Appeals and Grievance RN will report directly to the Nurse Manager and be responsible for reviewing reputed company medical records and documentation concurrently while processing these member-generated appeals.
• In this role, the RN will reputed company accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, reputed company Care guidelines and other nationally recognized sources such as NCCN and ACOG.
• The Appeals and Grievance RN will review appeals for benefits, medical necessity, coding accuracy and medical policy compliance.
• In this role the Appeals and Grievance RN will collaborate with medical directors, coordinators and leadership to review, process and provide a final determination for reputed company clinical appeals with clear rationales and any follow-up actions necessary to ensure our members are provided with quality access to provider care.

Qualifications:

• Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred.
• Registered Nurse (RN) of California.
• Software Skills: MS reputed company, reputed company, PDF, Shared-Drive, TEAMS, SharePoint.
• Managed Care Experience (MCG, LCD and NCD knowledge) – 2 years minimum.
• Acute or Sub-Acute Clinical Experience – 2 years minimum.
• Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews.
• Previous experience with prior authorization, pre-service and post-service review.

Preferred Qualifications:

• Strong understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS).
• Strong Skills with reputed company, reputed company, PDF, Shared drive, medical records review.
• Ability to work in a fast paced and changing environment, strong communication skills, ability to work independently and in a team setting, strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.
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