Appeals & Grievances Nurse Specialist RN

Job Description

Employer Industry: Health Insurance

Why consider this job opportunity…
– Opportunity for career advancement and growth within the organization
– Competitive pay and benefits package
– Remote work flexibility
– Supportive and collaborative work environment
– Chance to make a positive impact on member satisfaction

What to Expect (Job Responsibilities):
– Conduct intake/triage and appropriate classification of Clinical A&G and Pharmacy requests
– Investigate and resolve clinical member complaints and provider disputes
– Identify expedited cases and ensure resolution within 72 hours
– Work with external providers to obtain relevant medical records and communication documentation
– Prepare authorizations after approval by the Medical Director

What is Required (Qualifications):
– Associate’s Degree in Nursing
– At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment
– Good working knowledge of regulatory requirements/standards
– Excellent interpersonal and communication skills
– Registered Nurse (RN) – Active, current, and unrestricted California License

How to Stand Out (Preferred Qualifications):
– Bachelor’s Degree in Nursing
– Experience in appeals and grievances in a healthcare setting

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Talentify is not the EOR (Employer of Record) for this position. Our role in this specific opportunity is to connect outstanding candidates with a top-tier employer

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