Medical Review 3

Commercial Appeals And Grievance RN

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 (Top 3 Non-Negotiables):

• 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 (Nice To Have):

• 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 independently and in a team setting, strong clinical assessment skills, and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.

Disqualifiers/ Dislikes On Resumes:

• Gaps of employment not clearly explained, no license information listed, unorganized.

Education Requirements:

• 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) of California.