Appeals RN - Remote in NYC
Job Title: Grievance and Appeals Registered Nurse
Location: New York, New York 10017, United States...
Job Type: Full-Time
Schedule: Monday-Friday, 8am-4pm (with flexibility). Remote but ideally wants someone in the office 1 x a week
About Us:
We are dedicated to providing high-quality healthcare services. We are looking for a skilled Registered Nurse to join our Clinical Appeals team, which handles grievances, appeals, and external reviews for our health plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), and Select Health. Join our team to make a significant impact on patient care and compliance within a dynamic healthcare environment.
What You Will Do:
? Regulatory Compliance: Develop and maintain knowledge of state and federal regulatory requirements related to grievances and appeals for Medicare managed care, Medicaid, and managed long term care.
? Investigation and Review: Handle routine and complex grievances and appeals, focusing on issues such as medical necessity and quality of care. Collaborate with members, families, providers, and health plan departments to resolve issues.
? Timely Resolutions: Ensure all grievances and appeals are resolved within required timeframes, accurately documented, and compliant with regulatory standards.
? Service Coordination: Review and coordinate services according to plan benefits and medical criteria. Prepare records for physician review and manage prior authorization requests.
? External Reviews: Coordinate external case reviews with entities such as New York State (Fair Hearings) and CMS, ensuring compliance with regulatory requirements.
? Collaboration: Work with various departments, including Claims, Medical Management, and Legal, to facilitate grievance and appeal resolutions. Consult with Medical Directors as needed.
? Process Improvement: Contribute to the development of policies and procedures to enhance department operations and customer service.
? Data Management: Enter data and assist in compiling reports on grievance and appeals processes.
Qualifications:
Licenses and Certifications:
? Current registration to practice as a registered professional nurse in New York State required.
Education:
? Bachelor's Degree in Nursing required.
? Master's Degree in Nursing preferred.
Work Experience:
? Minimum of three years of progressive professional experience in healthcare, with at least two years in grievances and appeals or related areas such as medical or utilization management.
? Proficient in Microsoft Office (Word and Excel) and capable of working in a fast-paced environment managing multiple cases simultaneously.
If you are a dedicated RN looking for a challenging and rewarding role in a supportive and collaborative environment, apply today to join our team
Similar Remote Jobs
Appeals RN - Remote in NYC
Posted on: 16-07-2024 19:05
Call Center Representative - Remote | WFH
Posted on: 16-07-2024 19:05
Remote, 3rd shift, 11pm-7am- Customer Service Representative
Posted on: 16-07-2024 19:05
Remote Customer Service Representative ? Delta Airlines
Posted on: 16-07-2024 19:05
Part-Time Delta Airlines Data Entry Remote Jobs: Earn $/Hour
Posted on: 16-07-2024 19:05
Entry Level Apple Remote Jobs (Data Entry) $75000/Yearly - WFH
Posted on: 16-07-2024 19:05
Call Center Registered Nurse
Posted on: 16-07-2024 19:05
Delta Airline Customer Service Representative - Work At Home
Posted on: 16-07-2024 19:05
Delta Airlines Customer Service Representative (Remote)
Posted on: 16-07-2024 19:05
Clinical Appeals Nurse
Posted on: 16-07-2024 19:05
Paid Focus Group Participant - Flexible Part-Time Opportunity
Posted on: 07-09-2024 00:00
Order Management Representative Fully Remote
Posted on: 13-09-2024 00:00
Residential & Airbnb Cleaners Wanted in Spring!
Posted on: 15-12-2024 15:02
Spanish Bilingual Call Center Representative
Posted on: 30-12-2024 06:50
Customer Care Specialist Remote
Posted on: 03-10-2024 00:00
Remote Chat Assistant / Content Moderator (Entry Level / No...
Posted on: 16-07-2024 18:58
Walgreen Job Openings $28/Hour ? mysmartpros
Posted on: 19-11-2024 06:07
Side Hustles for College Student
Posted on: 08-08-2024 00:00
(Entry Level/No Experience) Walmart Data Entry Work From Home ?...
Posted on: 16-07-2024 18:55
Full-Time Delta Airlines Ticket Agent Position Available ? Competitive Salary & Benefits
Posted on: 18-12-2024 18:22