Grievance and Appeals RN

Job Title- Grievance and Appeals RN Location: Phoenix, AZ 85021 or Remote(AZ Time zone only) Duration: 6+ Months Contract Openings: # 4 Pay Rate: $40/Hour Note: Active multistate compact license or equivalent Primary Skills:Case Management, CMS Part C & Part D knowledge,Managed Care / Health Plan experience, Medical records review knowledge,Strong communication/customer service skills Experience in:Grievance & AppealsPrior AuthorizationClaimsMember ServicesJob Summary: We are seeking a Grievance & Appeals Nurse to review and investigate member/provider grievances and appeals for Medicare Part C and Part D. The nurse will review medical records, claims, authorizations, and health-plan benefits to make appropriate determinations while ensuring compliance with CMS requirements and timelines.Key Responsibilities:Review and investigate complex grievances and appeals. Evaluate medical records, claims, authorizations, and benefit documents. Apply CMS rules and health-plan policies to case determinations. Document investigations and resolutions accurately. Work with members, providers, and internal teams to resolve issues. Ensure cases are processed within required regulatory timelines. Required Skills & Qualifications:RN or LPN with an active, unrestricted Arizona nursing license.Associate’s degree in Nursing/Healthcare or Nursing Diploma. 5+ years of experience in grievances/appeals, prior authorization, claims, or member services. Knowledge of CMS Part C/Part D regulations. Experience reviewing medical records and health-plan benefits. Knowledge of ICD, CPT, HCPCS, and DRG codes. Strong communication, analytical, documentation, and customer service skills. Managed care/Medicare experience preferred.APOLIS2024