Appeals & Grievances Nurse Specialist RN

Employer Industry: Health Insurance

Why consider this job opportunity...
• Opportunity for career advancement and growth within the organization
• Competitive pay and benefits package
• Remote work flexibility
• Supportive and collaborative work environment
• Chance to make a positive impact on member satisfaction

What to Expect (Job Responsibilities):
• Conduct intake/triage and appropriate classification of Clinical A&G and Pharmacy requests
• Investigate and resolve clinical member complaints and provider disputes
• Identify expedited cases and ensure resolution within 72 hours
• Work with external providers to obtain relevant medical records and communication documentation
• Prepare authorizations after approval by the Medical Director

What is Required (Qualifications):
• Associate's Degree in Nursing
• At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment
• Good working knowledge of regulatory requirements/standards
• Excellent interpersonal and communication skills
• Registered Nurse (RN) - Active, current, and unrestricted California License

How to Stand Out (Preferred Qualifications):
• Bachelor's Degree in Nursing
• Experience in appeals and grievances in a healthcare setting

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Talentify is not the EOR (Employer of Record) for this position. Our role in this specific opportunity is to connect outstanding candidates with a top-tier employer

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