Grievance and Appeals BH Nurse - Remote | WFH

We are seeking a compassionate and detail-oriented individual to join our team as a Grievance and Appeals Coordinator. In this role, you will play a vital part in ensuring the fair resolution of complex grievances and appeals requests from both our valued members and providers.

Key Responsibilities...

Conduct thorough investigations and reviews of grievances and appeals, particularly focusing on cases of medical necessity.

Evaluate prospective, inpatient, or retrospective medical records for denied services, extracting and summarizing pertinent medical information for review by medical directors and external consultants.

Prepare well-founded recommendations regarding the approval or denial of appeals, forwarding them to the Medical Director for final approval.

Uphold regulatory timeframes by ensuring timely resolution of appeals and grievances.

Accurately document and log all appeal and grievance information using our tracking and mainframe systems.

Craft clear and professional written correspondence to providers, members, and regulatory bodies.

Demonstrate leadership by serving as a subject matter expert on appeals, grievances, and quality of care issues, providing guidance and support to both clinical and non-clinical team members.

Requirements

Minimum of 2 years of experience in a managed care healthcare setting, or an equivalent combination of education and experience.

Previous Experience In Behavioral Health Is Preferred.

Hold a current, active, and unrestricted RN license to practice within the scope of licensure in [insert state abbreviation].

Possess strong oral, written, and interpersonal communication skills, as well as exceptional problem-solving, facilitation, and analytical abilities.

Preferred certifications include MCG (Milliman Care Guidelines) and CMCN (Certified Managed Care Nurse).

A Bachelor's or Associate's degree in Nursing is preferred.

We are committed to fostering a supportive and inclusive work environment where every team member can thrive. If you are passionate about making a positive impact in healthcare and possess the necessary skills and qualifications, we encourage you to apply. Join us in our mission to deliver high-quality care and support to our members and providers.

Employment Type: Full-Time

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