RN Appeals and Grievances / Quality of Care

Active California Nursing License is required.
Compact License not accepted...
Multistate License not accepted.
Duties
• The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review.
• Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan.
• Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
• Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
• Perform other duties as assigned.
Required:
2 or more years of experience in Clinical Nursing and 2 years in MediCaid in a managed care/ health plan environment.
2 or more years of experience in Clinical Nursing and 2 years in MediCare in a managed care/ health plan environment.
Good working knowledge of regulatory requirements/standards.
Excellent interpersonal and communication skills.
Computer literacy and adaptability to computer learning.
Time management and priority setting skills.
Must be organized and a team player
Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies.
Schedule:
There are 4 schedules available, holidays will be required if they fall on your schedule:
Wednesday - Sunday: 7am-4pm Pacific Time
• Off days: Monday - Tuesday
Sunday - Thursday: 7am-4pm Pacific Time
• Off days: Friday - Saturday
Tuesday - Saturday: 7am-4pm Pacific Time
• Off days: Sunday - Monday
Monday - Friday: 8am - 5pm Pacific Time
• Off Days: Saturday - Sunday
Licenses/Certifications
Required
• Registered Nurse (RN) - Active, current and unrestricted California Nursing License
Job Types: Full-time, Contract
Pay: From $45.00 per hour
Expected hours: 40 per week
Schedule:
• Holidays
Application Question(s):
• Do you have managed care experience within a health plan?
• Do you current have an active California Nursing License?
• Do you have 2 years experience with MediCaid and MediCare?
Work Location: Remote

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