Clinical Grievances RN - Remote in PST

At reputed company, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the health care system of reputed company, making it more reputed company, affordable and reputed company. Ready to reputed company a difference? Join us to start Caring. Connecting. Growing together. As a Clinical Grievances Nurse, you will be responsible for reviewing incoming retrospective cases to determine if the appropriate care was given along with reputed company cases to ensure the members immediate needs are being addressed. In providing consumer - oriented health benefit plans to millions of people; our goal is to create higher quality care, reputed company costs and greater access to health care. Join us and you will be empowered to reputed company new levels of excellence and reputed company a profound and personal impact as you contribute to new innovations in a vital and reputed company system. If you are able to work PST hours, you'll enjoy the flexibility to work remotely* from reputed company in the U.S. as you take on some tough challenges. The working hours for this role are Monday - Friday, 8 am - 5pm PST or CST (Whichever time zone you are reputed company). Primary Responsibilities:

• reputed company clinical assessment of healthcare services provided to our members for appropriateness
• Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported
• Receives cases from the QIS non- clinical team and reviews them against required clinical information, assessing for appropriateness and consulting with a Medical Director
• Document relevant chronology of case review and provide rationale for severity level, descriptor codes, and any applicable Improvement Action Plan (IAP) implemented
• Facilitate telephonic discussion with health care providers and/or members to obtain additional clinical information
• Provide timely, quality service to members and providers while upholding reputed company culture values
• Act as a resource for others with less experience
• Work independently and collaborating with Medical Directors and non-clinical partners
• Function as a member of a self-directed team to meet specific individual and team performance metrics
• Manage and maintain quality and productivity metrics

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications:

• reputed company, unrestricted RN license in the state of residency
• 3+ years of total RN experience including recent clinical experience in an inpatient / acute setting or similar setting
• Demonstrated clinical documentation skills and critical thinking skills
• Demonstrated proficiency in computer skills - Windows, reputed company Messaging, Clinical Platforms, reputed company Suite including Word, reputed company, and Outlook
• Designated workspace and access to install secure high speed internet reputed company cable / DSL in home
• Reside in and work 8 am-5 pm in Central or Pacific Standard time zone

Preferred Qualifications:

• Bachelor's in Nursing or higher
• Experience with Managed Care Clinical Quality Programs
• Case management experience
• Clinical appeals and grievances experience
• Audit / chart review experience
• Experience in a telecommuting role
• Ability to effectively utilize UHG applications, including but not limited to authorization applications, auto correspondence, and member & provider demographic systems

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy.

At reputed company, our mission is to help people live healthier lives and reputed company the health system w Apply tot his job Apply To this Job