Appeals And Grievances Registered Nurse

Overview

• Provide clinical expertise in handling appeals and grievances in compliance with healthcare regulations.
• Investigate and resolve member and provider appeals and grievances efficiently.
• Ensure accurate documentation and timely communication throughout the appeals process.
• Collaborate with internal departments to ensure compliance and resolution.
• Prepare cases for review and external appeal processes.
• Utilize clinical knowledge to assess medical necessity and quality of care issues.
• Represent the organization at hearings and provide necessary documentation.
• Track and analyze trends to identify opportunities for improvement.
• Support compliance with CMS and DOH regulations.

Key Responsibilities & Duties

• Investigate and respond to clinical appeals and grievances submitted by members and providers.
• Conduct thorough reviews of appeals and grievances for medical necessity and quality of care.
• Prepare detailed case narratives and documentation for internal and external reviews.
• Collaborate with medical directors and other reviewers to finalize case assessments.
• Ensure compliance with CMS and DOH regulations in all processes.
• Generate acknowledgment letters and follow up on additional information requests.
• Track and trend clinical decisions to identify improvement opportunities.
• Represent the organization in fair hearings and prepare necessary documentation.
• Maintain accurate and timely documentation in relevant systems.

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 communication and collaboration skills to work effectively with teams.
• Ability to conduct thorough investigations and prepare detailed case narratives.
• Proficiency in documenting and tracking information in relevant systems.
• Experience in presenting cases to medical directors and external reviewers.
• Familiarity with CMS and DOH regulations and compliance standards.
• Commitment to professionalism and accountability in all tasks.