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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