Appeals And Grievances Registered Nurse

Overview

• Investigate and respond to clinical appeals and grievances per regulatory guidelines.
• Conduct thorough investigations and assessments of appeals and grievances.
• Prepare cases for review, including documentation and medical record analysis.
• Collaborate with internal departments to ensure compliance and resolution.
• Present cases to medical directors and external review entities.
• Maintain accurate documentation and tracking of case progress.
• Ensure timely submission of correspondence and documents.
• Represent the organization in hearings and prepare necessary materials.

Key Responsibilities & Duties

• Investigate appeals and grievances related to clinical determinations and quality of care.
• Perform clinical reviews for medical necessity and regulatory compliance.
• Coordinate with departments to gather supporting documentation.
• Prepare detailed case narratives and summaries for review.
• Ensure compliance with CMS and DOH regulations in case handling.
• Track and analyze trends in appeals and grievances for quality improvement.
• Provide timely and accurate responses to external review requests.
• Represent the organization in fair hearings and prepare case files.

Job Requirements

• Bachelor of Science in Nursing (BSN) is required.
• Minimum of 2 years of managed care or hospital-based case management experience.
• Knowledge of appeals and grievances processes and regulations.
• Strong communication and collaboration skills.
• Proficiency in documentation and case tracking systems.
• Ability to analyze and interpret clinical data and regulations.
• Experience in preparing cases for medical director and external reviews.
• Commitment to professionalism and adherence to organizational standards.