Grievance and Appeals RN

Job 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.