Appeals RN - Remote in NYC
Job Title: Grievance and Appeals Registered Nurse
Location: New York, New York 10017, United States...
Job Type: Full-Time
Schedule: Monday-Friday, 8am-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 our team to make a significant impact on patient care and compliance within a dynamic healthcare environment.
What You Will Do:
Regulatory Compliance: Develop and maintain knowledge of state and federal regulatory requirements related to grievances and appeals for Medicare managed care, Medicaid, and managed long term care.
Investigation and Review: Handle routine and complex 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 all grievances and appeals are resolved within 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 New York 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:
Current registration to practice as a registered professional nurse in New York 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 related areas such as medical or utilization management.
Proficient in Microsoft Office (Word and Excel) 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 our team
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