Appeals & Grievance Registered Nurse (RN) 100 Remote for CA Residents

Overview: Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Appeals and Grievance Registered Nurse (RN).

Candidate must be authorized to work in USA without requiring sponsorship

* • *************************************************************** • ** Location: 100% Remote for California Residents

• ** Duration: Through the end of year 12/26/2025 w/ possibility of extensions or conversion to FTE role

Notes: Schedule: Monday–Friday, 08:00 AM – 05:00 PM. Description:

• The Commercial Appeals and Grievance RN reviews and processes appeals resulting from a member generated pre-service or post-service concern or complaint.
• The Commercial Appeals and Grievance RN will report directly to the Nurse Manager and be responsible for reviewing all medical records and documentation concurrently while processing these member-generated appeals.
• In this role, the RN will perform accurate and timely first level reviews according to company and regulatory standards, utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines and other nationally recognized sources such as NCCN and ACOG.
• The Appeals and Grievance RN will review appeals for benefits, medical necessity, coding accuracy and medical policy compliance.
• In this role the Appeals and Grievance RN will collaborate with medical directors, coordinators and leadership to review, process and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure our members are provided with quality access to provider care.

Qualifications:

• Associate Degree of Nursing (ADN), Bachelor of Science in Nursing (BSN) preferred.
• Registered Nurse (RN) of California.
• Software Skills: MS Excel, Microsoft, PDF, Shared-Drive, TEAMS, SharePoint.
• Managed Care Experience (MCG, LCD and NCD knowledge) – 2 years minimum.
• Acute or Sub-Acute Clinical Experience – 2 years minimum.
• Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews.
• Previous experience with prior authorization, pre-service and post-service review.

Preferred Qualifications:

• Strong understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS).
• Strong Skills with Excel, Microsoft, PDF, Shared drive, medical records review.
• Ability to work in a fast paced and changing environment, strong communication skills, ability to work independently and in a team setting, strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.
• *********************************************************************

I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you. Satwinder “Sat” Singh Lead Technical Recruiter Company Overview: Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward. Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws. Apply To This Job