Appeals And Grievances Registered Nurse

Overview

• Provide clinical expertise in handling appeals and grievances for healthcare services.
• Investigate and respond to clinical appeals and grievances in compliance with regulations.
• Collaborate with internal departments to ensure accurate case documentation and resolution.
• Prepare detailed case narratives and summaries for review and regulatory compliance.
• Utilize advanced clinical knowledge for effective case investigation and resolution.
• Support fair hearing presentations and follow-up actions post hearings.
• Track and analyze clinical decisions for quality improvement opportunities.
• Ensure timely documentation and communication with stakeholders.
• Adhere to organizational standards and regulatory requirements.

Key Responsibilities & Duties

• Investigate appeals and grievances related to clinical services and quality of care.
• Conduct clinical reviews for medical necessity and compliance with policies.
• Prepare cases for external reviews and regulatory hearings.
• Collaborate with medical directors and reviewers for case analysis.
• Generate acknowledgment letters and follow up on information requests.
• Document all actions and findings in designated systems.
• Interface with various departments to ensure comprehensive case handling.
• Track compliance with appeals and grievances processes.
• Attend and represent cases at fair hearings as required.

Job Requirements

• Bachelor of Science in Nursing (BSN) required.
• Minimum of 2 years of managed care or hospital-based utilization/case management experience.
• Knowledge of appeals and grievances processes and regulations.
• Strong customer service and communication skills.
• Proficiency in clinical documentation and case analysis.
• Ability to collaborate effectively across departments.
• Experience in preparing cases for regulatory and external reviews.
• Familiarity with CMS and DOH regulations preferred.
• Detail-oriented with strong organizational skills.