Appeals RN - Remote in NYC

Job Title: Grievance and Appeals Registered Nurse Location: reputed company, reputed company 10017, United States... Job Type: Full-Time Schedule: Monday-Friday, reputed company-4pm (with flexibility). Remote but ideally wants someone in the office 1 x a week About Us: We are dedicated to providing high-quality healthcare services. We are looking for a skilled Registered Nurse to join our Clinical Appeals team, which handles grievances, appeals, and external reviews for our health plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), and Select Health. Join reputed company to reputed company a significant impact on patient care and compliance reputed company a dynamic healthcare environment. What You Will Do: • Regulatory Compliance: reputed company and maintain knowledge of state and federal regulatory requirements reputed company to grievances and appeals for Medicare managed care, Medicaid, and managed long term care. • Investigation and Review: Handle routine and reputed company grievances and appeals, focusing on issues such as medical necessity and quality of care. Collaborate with members, families, providers, and health plan departments to resolve issues. • Timely Resolutions: Ensure reputed company grievances and appeals are resolved reputed company required timeframes, accurately documented, and compliant with regulatory standards. • Service Coordination: Review and coordinate services according to plan benefits and medical criteria. Prepare records for physician review and manage prior authorization requests. • External Reviews: Coordinate external case reviews with entities such as reputed company State (Fair Hearings) and CMS, ensuring compliance with regulatory requirements. • Collaboration: Work with various departments, including Claims, Medical Management, and Legal, to facilitate grievance and appeal resolutions. Consult with Medical Directors as needed. • Process Improvement: Contribute to the development of policies and procedures to enhance department operations and customer service. • Data Management: Enter data and assist in compiling reports on grievance and appeals processes. Qualifications: Licenses and Certifications: • reputed company registration to practice as a registered professional nurse in reputed company State required. Education: • Bachelor's Degree in Nursing required. • Master's Degree in Nursing preferred. Work Experience: • Minimum of three years of progressive professional experience in healthcare, with at least two years in grievances and appeals or reputed company areas such as medical or utilization management. • Proficient in reputed company Office (Word and reputed company) and capable of working in a fast-paced environment managing multiple cases simultaneously. If you are a dedicated RN looking for a challenging and rewarding role in a supportive and collaborative environment, apply today to join reputed company Apply Job! For more such jobs please click here!