RN Appeals and Grievances

Active RN License for D.C. is required

D.C. is NOT compact or multistate...

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.

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.

Licenses/Certifications

Required
• Registered Nurse (RN) - Active, current and unrestricted District of Columbia

Job Types: Full-time, Contract

Pay: $45.00 per hour

Expected hours: 40 per week

Schedule:
• 8 hour shift
• Monday to Friday

Application Question(s):
• Do you have 2 years experience with MediCaid?
• Do you have managed care experience within a health plan?
• Do you current have an active DC RN License?

Work Location: Remote

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