RN Appeals and Grievances / Quality of Care
Active California Nursing License is required. Compact License not accepted... Multistate License not accepted. Duties The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review. Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan. Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation. Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director. Perform other duties as assigned. Required: 2 or more years of experience in Clinical Nursing and 2 years in MediCaid in a managed care/ health plan environment. 2 or more years of experience in Clinical Nursing and 2 years in MediCare in a managed care/ health plan environment. Good working knowledge of regulatory requirements/standards. Excellent interpersonal and communication skills. Computer literacy and adaptability to computer learning. Time management and priority setting skills. Must be organized and a team player Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies. Schedule: There are 4 schedules available, holidays will be required if they fall on your schedule: Wednesday - Sunday: 7am-4pm Pacific Time Off days: Monday - Tuesday Sunday - Thursday: 7am-4pm Pacific Time Off days: Friday - Saturday Tuesday - Saturday: 7am-4pm Pacific Time Off days: Sunday - Monday Monday - Friday: 8am - 5pm Pacific Time Off Days: Saturday - Sunday Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California Nursing License Job Types: Full-time, Contract Pay: From $45.00 per hour Expected hours: 40 per week Schedule: Holidays Application Question(s): Do you have managed care experience within a health plan? Do you current have an active California Nursing License? Do you have 2 years experience with MediCaid and MediCare? Work Location: Remote Apply Job! For more such jobs please click here!