RN Appeals and Grievances
Active RN License for D.C. is required
D.C. is NOT compact or multistate...
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.
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.
Licenses/Certifications
Required
? Registered Nurse (RN) - Active, current and unrestricted District of Columbia
Job Types: Full-time, Contract
Pay: $45.00 per hour
Expected hours: 40 per week
Schedule:
? 8 hour shift
? Monday to Friday
Application Question(s):
? Do you have 2 years experience with MediCaid?
? Do you have managed care experience within a health plan?
? Do you current have an active DC RN License?
Work Location: Remote
Similar Remote Jobs
RN Appeals and Grievances
Posted on: 16-07-2024 19:05
Remote Customer Service Representative ? Delta Airlines
Posted on: 16-07-2024 19:05
Hybrid Bilingual IT Help Desk Customer Service Representative
Posted on: 16-07-2024 19:05
Microsoft Dyanmics 365 Engineer
Posted on: 16-07-2024 19:05
UPS Remote Jobs (Data Entry) $30/Per Hour ? Entry Level
Posted on: 16-07-2024 19:05
Live chat specialist
Posted on: 16-07-2024 19:05
Hourly Live Chat Assistant (Remote / No Experience)
Posted on: 16-07-2024 19:05
Entry Level - Remote Data Entry Clerk
Posted on: 16-07-2024 19:05
Manager, Associate Relations (Remote-Eligible)
Posted on: 16-07-2024 19:05
Human Resources Generalist II - Fully Remote (AZ, FL, IL, IN, NC...
Posted on: 16-07-2024 19:05
Residential Direct Support Prof. Cape Wide $18-$20 per hour
Posted on: 27-09-2024 00:00
Dietetic Technician I
Posted on: 14-11-2024 08:01
AIML - Senior Machine Learning Manager, Privacy ML
Posted on: 22-10-2024 05:26
Customer Support Representative, Employee Experience (Hybrid)
Posted on: 22-09-2024 00:00
Early Childhood Educator (Online)
Posted on: 24-01-2025 00:00
Sales Merchandiser Relief
Posted on: 20-01-2025 00:00
Regional Account Manager of University Partnerships - DMV
Posted on: 08-01-2025 08:06
Atlas Air Worldwide First Officer
Posted on: 10-10-2024 00:00
Work From Home Amazon Data Entry Jobs No Experience Remote - Part-Time
Posted on: 23-01-2025 00:00
Amazon Marketplace Account Specialist - Austin, TX or Remote
Posted on: 16-07-2024 18:47