Medical Review RN IV

Medical Review RN IV – Commercial Appeals & Grievance Nurse

Location: Remote – Candidate Must Reside in California

Duration: 6+ Months Contract-to-Hire

Schedule: Monday-Friday | 9:00 AM – 5:00 PM

Pay Range: XXXXXXXXXXX - $50.00 Per hr. on w2.

Position Overview

The Commercial Appeals & Grievance RN is responsible for reviewing and processing member-generated pre-service and post-service appeals, grievances, and clinical determinations. This role requires extensive medical record review, clinical assessment, and application of regulatory and medical necessity guidelines to ensure accurate and timely appeal determinations.

Working closely with Medical Directors, Utilization Management teams, Quality, Pharmacy, Claims, and Customer Service departments, the RN will evaluate appeals related to medical necessity, benefit coverage, coding accuracy, and medical policy compliance while ensuring adherence to regulatory requirements and organizational standards.

The ideal candidate will possess strong managed care experience, utilization management knowledge, clinical review expertise, and the ability to independently analyze complex medical records and documentation.

Key Responsibilities

• Appeals & Grievance Review
• Review and process first-level clinical appeals and grievances for Commercial and Medicare members.
• Conduct comprehensive medical record reviews and evaluate supporting clinical documentation.
• Analyze pre-service and post-service appeals involving medical necessity, benefit determinations, coding accuracy, and medical policy compliance.
• Prepare clear, accurate, and well-supported clinical determinations and rationale documentation.

• Clinical Review & Medical Necessity Evaluation
• Apply National Coverage Determination (NCD), Local Coverage Determination (LCD), MCG (Milliman Care Guidelines), NCCN, ACOG, and other nationally recognized clinical guidelines.
• Evaluate services for appropriateness, medical necessity, and coverage eligibility.
• Identify discrepancies, omissions, or inaccuracies in clinical documentation and medical determinations.
• Ensure compliance with company policies, regulatory standards, and accreditation requirements.

• Collaboration & Communication
• Partner with Medical Directors regarding complex appeal cases and clinical determinations.
• Collaborate with Utilization Management, Pharmacy, Claims, Customer Service, Quality, and Care Management teams.
• Communicate appeal outcomes and required follow-up actions effectively.
• Participate in clinical discussions to support accurate and consistent decision-making.

• Compliance & Quality
• Maintain compliance with NCQA, CMS, DMHC, DHCS, and organizational requirements.
• Ensure turnaround times and regulatory deadlines are consistently met.
• Support quality improvement initiatives related to appeals, grievances, and utilization management processes.
• Maintain accurate documentation and case records.

Required Qualifications

• Education
• Associate Degree in Nursing (ADN) required
• Bachelor of Science in Nursing (BSN) preferred

• Licensure
• Active California Registered Nurse (RN) License required

• Required Experience
• Minimum 2 years of Managed Care experience
• Minimum 2 years of Acute Care or Sub-Acute Clinical Nursing experience
• Experience with Medical Necessity Review and Utilization Management
• Experience reviewing Commercial and Medicare benefits
• Prior Authorization experience
• Pre-Service and post-service review experience
• Appeals and Grievances experience strongly preferred

• Required Knowledge
• MCG (Milliman Care Guidelines)
• National Coverage Determinations (NCD)
• Local Coverage Determinations (LCD)
• Medical Record Review
• Medical Necessity Determinations
• Medicare and Commercial Health Plan Benefits

• Technical Skills
• Microsoft Excel
• Microsoft Office Suite
• Adobe PDF
• Microsoft Teams
• SharePoint
• Shared Drive Management

• Preferred Qualifications
• Appeals & Grievance Nursing experience
• Clinical Denials Management experience
• Utilization Review Nursing experience
• NCQA, CMS, DMHC, and DHCS regulatory knowledge
• Strong analytical and clinical assessment skills
• Experience working in fast-paced managed care environments
• Excellent written and verbal communication skills