RN Appeals and Grievances
2 days ago
Job description:
Our client, a large nonprofit hospice and palliative care company is seeking a qualified candidate to join their team. In this role, we are looking for someone who is a Registered Nurse in the state of New York to work in the appeals and grievances department. This is a fantastic opportunity for a registered nurse to work for a nonprofit healthcare company
Pay $56.00 per hour
The job is a full time role with possibility of conversion in 2026.
4 days remote 1 day onsite
Job responsibilities for the Registered Nurse:
Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal
Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services.
Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas.
Tracks departments compliance with requested action as a component of the Appeals and Grievance and determination process.
Presents cases to Appeals & Grievances File Review.
Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing
Qualifications needed for Registered Nurse:
Graduate of accredited nursing program.
BSN or equivalent experience required.
2 years of managed care or hospital-based utilization/ case management experience
2 years minimum of clinical experience
Licensed Registered Nurse in New York State
Must be proficient in MS Word, Excel and desktop software knowledge preferred.
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