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Appeals & Grievances Nurse Specialist RN
This job is now closed
Job Description
- Req#: 24-07529
Employer Industry: Health Insurance
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Competitive pay and benefits package
- Remote work flexibility
- Supportive and collaborative work environment
- Chance to make a positive impact on member satisfaction
What to Expect (Job Responsibilities):
- Conduct intake/triage and appropriate classification of Clinical A&G and Pharmacy requests
- Investigate and resolve clinical member complaints and provider disputes
- Identify expedited cases and ensure resolution within 72 hours
- Work with external providers to obtain relevant medical records and communication documentation
- Prepare authorizations after approval by the Medical Director
What is Required (Qualifications):
- Associate's Degree in Nursing
- At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment
- Good working knowledge of regulatory requirements/standards
- Excellent interpersonal and communication skills
- Registered Nurse (RN) - Active, current, and unrestricted California License
How to Stand Out (Preferred Qualifications):
- Bachelor's Degree in Nursing
- Experience in appeals and grievances in a healthcare setting
#HealthInsurance #CareerGrowth #RemoteWork #CompetitivePay #HealthcareServices
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