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Medical Appeals/Grievance Specialist II - Registered Nurse (REMOTE - AZ)
This job is now closed
Job Description
- Req#: R5839
Employer Industry: Health Insurance
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Flexible hybrid work environment with remote options available for Arizona residents
- Supportive and collaborative work culture
- Engage in meaningful work that impacts member health and satisfaction
- Competitive benefits package including health insurance and other perks
What to Expect (Job Responsibilities):
- Conduct in-depth analysis and clinical review of provider appeals, grievances, and corrected claims across all lines of business
- Respond to a high volume of health insurance-related inquiries through effective written and verbal communication
- Analyze medical records and apply medical necessity criteria to determine the appropriateness of requests
- Maintain accurate records and meet performance goals as defined by departmental guidelines
- Collaborate with various internal departments and external entities to resolve customer inquiries
What is Required (Qualifications):
- Level I: 1 year of experience in clinical and health insurance or a related healthcare field
- Level II: 3 years of experience in clinical and health insurance or a related healthcare field, plus 1 year of managed care experience
- Level III: 5 years of experience in clinical and health insurance or a related healthcare field, plus 2 years of managed care experience
- Level IV: 8 years of experience in clinical and health insurance or a related healthcare field, plus 3 years of satisfactory job performance in managed care
- Associate's Degree in a healthcare field of study or Nursing Diploma
How to Stand Out (Preferred Qualifications):
- 3-9 years of experience in clinical and health insurance or a related healthcare field
- Working knowledge of eviCore, MCG, and McKesson InterQual® criteria
- Advanced ability to interpret contract language and benefits
- Bachelor's Degree in Nursing or a related field of study
#HealthInsurance #CareerOpportunity #RemoteWork #ClinicalReview #MemberSatisfaction
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