Clinical Appeals and Grievances Nurse Specialist

1 week ago


Étreux, Hauts-de-France, United States AllWays Health Partners Full time
Clinical Appeals and Grievances Nurse Role Overview

This position is a key component of our Appeals and Grievance review process at AllWays Health Partners. The Clinical Appeals and Grievance Coordinator (RN) works under the direction of the Director of Appeals and Grievances to ensure that clinical/pharmacy appeal cases meet contractual, regulatory, and business goals.

Responsibilities
  • In conjunction with other appeal team members, ensures timely resolution of clinical/pharmacy appeals and grievances to meet regulatory timeframes.
  • Interacts directly with providers and their staff to obtain additional clinical information, as well as with members or their advocates to understand the full intent of the appeal or clinical grievance.
  • Reviews clinical/pharmacy appeal cases and provides recommendations to the medical director team based on analysis of the clinical material.
  • Works closely with pharmacy staff on pharmacy-related reviews in preparation for physician review if needed.
  • Identifies cases that may require specialty review and expedites submission of cases to external vendors for this purpose.
  • Analyzes and completes written summaries on clinical cases.
  • Maintains compliance with all required turnaround times and regulatory requirements.

Requirements
  • Bachelor's Degree.
  • RN degree with Massachusetts License.
  • Minimum of 2 years of clinical experience.
  • Minimum of 3 years utilization review and/or appeals and grievance experience either with a health plan or healthcare facility.
  • Minimum of 5 years' experience working with members, providers, and internal staff on complex and sensitive requests for clinical services.
  • Minimum of 5 years' experience working in multiple data systems.
  • Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage.

Estimated Salary: $83,000 - $108,000 per year, depending on experience.

The ideal candidate will have strong critical thinking, analytical, and organizational skills, as well as excellent oral and written communication skills. They will be able to work independently and as part of a team, and have a strong aptitude for technology-based solutions.

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