Quality/Grievance and Appeals-100% remote-Health Plan experience...

Remote, USA Full-time Posted 2025-07-03

Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.

Investigation, and resolution of clinical member complaints (grievances/appeals... utilizing all regulatory requirements. Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours.

Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.

Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).

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.

Job Types: Full-time, Contract

Pay: $40.00 per hour

Expected hours: 40 per week

Experience:
? Health insurance: 2 years (Required)
? Medicare: 2 years (Required)
? Appeals: 2 years (Required)
? Quality of Care: 2 years (Required)

License/Certification:
? California RN License (Required)

Work Location: Remote

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Quality/Grievance and Appeals-100% remote-Health Plan experience...

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