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!