Remote Nurse Specialist | WFH Grievance & Appeals

Job Title: Remote Nurse Specialist - Grievance & Appeals

Compensation

Hourly Rate: \(43.00 - \)69.00/hr (based on experience and internal scale)

Work Environment

Full-time, Remote

Job Overview

We are in search of a dedicated and seasoned Temporary Nurse Specialist for Grievance & Appeals to become an integral part of our innovative healthcare team. This role will involve overseeing medical appeals and state hearing reviews across various business lines, as well as managing both expedited and standard requests. Your expertise will ensure that all cases are addressed in compliance with applicable regulations, standards, and organizational policies. You will be responsible for investigating and preparing detailed case narratives, precisely articulating facts, and advocating for our organization's position before Administrative Law Judges. Additionally, you will draft and review resolution letters concerning clinical criteria and regulatory requirements.

Key Responsibilities

• Excel in a mission-driven environment emphasizing high-quality performance, exceptional customer service, dignity, and accountability.
• Conduct clinical reviews in accordance with established guidelines and monitor cases related to medical decisions and quality of care.
• Ensure timely completion of all cases following both state and federal regulatory requirements.
• Present well-founded recommendations to physician reviewers based on clinical assessments and organizational policies.
• Resolve intricate and sensitive member issues within stipulated timelines.
• Maintain database accuracy by diligently entering case actions relevant to assigned cases.
• Analyze and present cases during Grievance and Appeals Review Subcommittee meetings.
• Manage state hearing cases while guiding members through the appeals process and their hearing rights.
• Assist members with service coordination and effectively communicate case statuses and outcomes.
  
  

Qualifications

• High School diploma or equivalent.
• Minimum of 5 years of experience within healthcare/managed care, ideally in Grievances and Appeals, Utilization Management, or Quality Management.
• An equivalent combination of education and experience that demonstrates the ability to successfully perform the essential duties of the position.
  
  

Career Growth Opportunities

As a Temporary Grievance & Appeals Nurse Specialist, you will have the opportunity to engage in departmental meetings, training, and audits, paving the way for professional development and skill enhancement as you contribute to our team’s success.

Company Culture And Values

Our organization fosters a mission-driven culture that champions high-quality performance and customer service, ensuring that dignity and accountability are at the forefront of our operations. We encourage collaboration and cultivate an environment where all team members can thrive, contributing meaningfully to our shared goals.

Physical Environment

The work setting is predominantly indoor and sedentary, with a possibility for schedule adjustments and variable work hours, including some travel as needed. The position does not expose you to harmful environmental conditions, and the noise level is generally moderate.

How To Apply

If you are a committed healthcare professional eager to take on a challenging and fulfilling role, we invite you to submit your resume, emphasizing your relevant experience and qualifications. We look forward to the opportunity to welcome you to our esteemed team!

Equal Opportunity Employer

Employment Type: Contractor