Medical Review (Registered Nurse)

Commercial Appeals And Grievance RN

Payrate: $42.00- $44.00/hr. Summary: 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 all medical records and documentation concurrently while processing these member-generated appeals. In this role, the RN will perform accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman 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 all clinical appeals with clear rationales and any follow up actions necessary to ensure our members are provided with quality access to provider care.

Required Skills:

• 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 Skills:

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

Requirements:

• Education: Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred
• Software Skills Required: Excel, Microsoft, PDF, Shared-Drive, TEAMS, Share-Point
• Required Certifications: Registered Nurse (RN)

Pay Transparency: The typical base pay for this role across the U.S. is: $42.00- $44.00/hour . Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, lifeion benefits, health savings accounts with qualified medical plan enrollment, 10 paid days off, 3 days paid bereavement leave, 401(k) plan participation with employer match, life and disability insurance, commuter benefits, dependent care flexible spending account, accident insurance, critical illness insurance, hospital indemnity insurance, accommodations and reimbursement for work travel, and discretionary performance or recognition bonus. Sick leave and mobile phone reimbursement provided based on state or local law. Consent to Communication and Use of AI Technology: By submitting your application for this position and providing your email address(es) and/or phone number(s), you consent to receive text (SMS), email, and/or voice communication whether automated (including auto telephone dialing systems or automatic text messaging systems), pre-recorded, AI-assisted, or individually initiated from Aditi Consulting, our agents, representatives, or affiliates at the phone number and/or email address you have provided. These communications may include information about potential opportunities and information. Message and data rates may apply. Message frequency may vary. You represent and warrant that the email address(es) and/or telephone number(s) you provided to us belong to you and that you are permitted to receive calls, text (SMS) messages, and/or emails at these contacts. You also acknowledge and agree to Aditi Consulting LLC's use of AI technology during the sourcing process, including calls from an AI Voice Recruiter. AI is used solely to gather data and does not replace human-based decision-making in employment decisions. Calls may be recorded. Consent is not a condition of purchasing any property, goods, or services. You may revoke your consent at any time by replying "STOP" to messages or by contacting View email address on click.appcast.io. For information about our collection, use, and disclosure of applicant's personal information as well as applicants' rights over their personal information, please see our Privacy Policy.