RN - Grievance and Appeals Nurse

Top Healthcare company is looking for a Registered Nurse to work remotely as a Grievance and Appeals nurse.

***MUST hold an Arizona RN license***

This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines.

Maintains a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance.

Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.

Participates in CMS and other audits and related activities as required.

Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.

Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.

Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day.

**The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.**

Perform all other duties as assigned.

REQUIRED COMPETENCIES

1. Required Job Skills

Working knowledge of CMS Managed Care Manual Chapter 13

Beneficiary Grievances

Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances

Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes

Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software.

Math, communications and business skills normally demonstrated by a high school degree or equivalent.

2. Required Professional Competencies

Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.

Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation. null

Required Work Experience

5 years of work experience with CMS member services, prior authorizations, appeal and grievance, or claims functions.

Required Education

Associate's Degree in a healthcare field of study or Nursing Diploma

Required Licenses

Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona (a state in the United States).

Prefered Work Experience

1-3 years prior work experience in a managed care environment.

Preferred Education

Bachelor's degree in general studies, nursing, or business administration

CONTRACT until 12/31/2026

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on randstadusa.com.


Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).


This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.