Grievance & Appeals Nurse

Position Purpose

Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

Key Details: Candidate must hold California RN Licensure. This position is remote and will work PST hours.

• Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue cases.
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations
• Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines.
• Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
• May act as liaison between the provider and business to resolve issues
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience

LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred.

License/Certification: Current state's RN, LPN, or LVN license.

Must be licensed in CA.

Pay Range: $27.02 - $48.55 per hour