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

Pride-Health offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance and employee discounts with preferred vendors.

Equal Employment Opportunity

Pride-Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride-Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.

Only applicable for San Francisco Candidates: Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation.

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