Remote- Grievance and Appeals Nurse

Pride Health is hiring a Grievances and Appeals Nurse for a well-known client! (Remote Contract)

Schedule: 5x8s Day shift

Contract: 6 months

Pay Rate: 40-45/hr

Primary Responsibilities:

• Serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions
• Investigates and identifies member, provider, and/or claim processing appeals and customer service grievance issues
• Ensures investigation, resolution, and responses are processed promptly in accordance with CMS requirements and timelines
• Maintains a thorough understanding of Health Plan operations and business unit processes, workflows, and system requirements, including plan benefits outlined in EOC documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance
• Maintains current knowledge of CMS rules and regulations related to grievance and appeal processes
• Participates in CMS and other audits and related activities as required
• Coordinates investigation and resolution of complex grievance and appeal issues
• Reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases
• Collects and analyzes supporting documentation and makes appropriate grievance and appeal determinations

Required Qualifications:

• 5 years of work experience with CMS member services, prior authorizations, appeals and grievances, or claims functions
• Associate’s degree in a healthcare field of study or nursing diploma
• Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona
• 1–3 years of prior work experience in a managed care environment (preferred)
• Bachelor’s degree in general studies, nursing, or business administration (preferred)
• Working knowledge of CMS Managed Care Manual Chapter 13 and CMS Prescription Drug Benefit Manual Chapter 18
• Knowledge of healthcare billing and claims adjudication processes
• Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes