Drive impactful healthcare appeals and grievances processes with regulatory compliance. Enhance clinical expertise in managed care and case management. Collaborate across departments to ensure quality care delivery and patient satisfaction.
Appeals And Grievances Registered Nurse
in Healthcare + Life Sciences ContractJob Detail
Job Description
Overview
- Provide clinical expertise in managing appeals and grievances for healthcare services, ensuring compliance with regulations and organizational standards.
- Investigate and resolve clinical appeals and grievances with a focus on quality care and patient satisfaction.
- Collaborate with cross-functional teams to ensure accurate documentation and resolution of cases.
- Prepare detailed case narratives and summaries for regulatory compliance and review purposes.
- Utilize advanced clinical knowledge to support fair hearing presentations and post-hearing follow-ups.
- Analyze clinical decisions to identify opportunities for quality improvement and process enhancements.
- Ensure timely communication and documentation with all stakeholders involved in the appeals process.
- Adhere to organizational standards and regulatory requirements while handling cases.
Key Responsibilities & Duties
- Investigate appeals and grievances related to clinical services, ensuring thorough analysis and resolution.
- Conduct clinical reviews to assess medical necessity and compliance with healthcare policies.
- Prepare cases for external reviews and regulatory hearings, ensuring comprehensive documentation.
- Collaborate with medical directors and reviewers to analyze and resolve complex cases.
- Generate acknowledgment letters and follow up on information requests promptly.
- Document all actions and findings in designated systems for accurate record-keeping.
- Interface with various departments to ensure comprehensive handling of appeals and grievances.
- Attend and represent cases at fair hearings, providing clinical expertise as required.
Job Requirements
- Bachelor of Science in Nursing (BSN) required, with strong clinical knowledge.
- Minimum of 2 years of experience in managed care or hospital-based utilization/case management.
- Knowledge of appeals and grievances processes and healthcare regulations.
- Excellent customer service and communication skills for effective stakeholder engagement.
- Proficiency in clinical documentation and case analysis tools and systems.
- Ability to collaborate effectively across departments and with external reviewers.
- Experience in preparing cases for regulatory and external reviews preferred.
- Familiarity with CMS and DOH regulations is advantageous.
- Detail-oriented with strong organizational and analytical skills.
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