Remote- Grievance and Appeals Nurse

Primary Responsibilities

• Serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions
• Investigates and identifies member, provider, and/or claim processing appeals and customer service grievance issues
• Ensures investigation, resolution, and responses are processed promptly in accordance with CMS requirements and timelines
• Maintains a thorough understanding of Health Plan operations and business unit processes, workflows, and system requirements, including plan benefits outlined in EOC documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance
• Maintains current knowledge of CMS rules and regulations related to grievance and appeal processes
• Participates in CMS and other audits and related activities as required
• Captures and analyzes supporting documentation and makes appropriate grievance and appeal determinations

Required Qualifications

• 5 years of work experience with CMS member services, prior authorizations, appeals and grievances, or claims functions
• Associate’s degree in a healthcare field of study or nursing diploma
• Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona
• 1-3 years of prior work experience in a managed care environment (preferred)
• Bachelor’s degree in general studies, nursing, or business administration (preferred)
• Working knowledge of CMS Managed Care Manual Chapter 13 and CMS Prescription Drug Benefit Manual Chapter 18
• Knowledge of healthcare billing and claims adjudication processes
• Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes

Benefits

• Comprehensive healthcare coverage (medical, dental, and vision plans)
• Supplemental coverage (accident insurance, critical illness insurance and hospital indemnity)
• 401(k)-retirement savings
• Life & disability insurance
• An employee assistance program
• Legal support
• Auto, home insurance, pet insurance
• Employee discounts with preferred vendors

Pay

Pay Rate: 40-45/hr

Schedule

Day shift

Qualifications

5 years of work experience with CMS member services, prior authorizations, appeals and grievances, or claims functions

Associate’s degree in a healthcare field of study or nursing diploma

Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona

1-3 years of prior work experience in a managed care environment (preferred)

Bachelor’s degree in general studies, nursing, or business administration (preferred)

Working knowledge of CMS Managed Care Manual Chapter 13 and CMS Prescription Drug Benefit Manual Chapter 18

Knowledge of healthcare billing and claims adjudication processes

Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes