Remote Medicare Appeals and Grievances RN – California

Position: Appeals and Grievances RN

Location: Remote in CA

Duration: 6+ Month Contract to HIRE

Pay Rate: $51/hr

Schedule: M-F: 8-5 OR 8:30 – 5:30p Pacific

Day-to-Day Responsibilities:

The Appeals and Grievances RN will support the Appeals and Grievances team by conducting clinical reviews of member appeals and grievances. These reviews stem from preservice, post-service, or claim denials. Reporting directly to the Appeals and Grievances Manager, the RN will be responsible for:

• Performing first-level appeal reviews for Medicare members.
• Utilizing National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines.
• Reviewing cases based on pharmacy policies and nationally recognized clinical sources such as MCG, NCCN, and ACOG.
• Assessing appeals for medical necessity, benefit coverage, and coding accuracy.
• Documenting findings clearly and accurately in the system.
• Applying clinical knowledge and judgment independently while adhering to regulatory and organizational standards.

Job Requirement:

• The ideal candidate will possess strong experience in managed care or health insurance settings and must have a Bachelor’s Degree in Nursing. Advanced certifications are highly desirable.
• Utilization Managment
• 2–4 years of experience in health insurance, managed care, or a related clinical review field.
• Ability to act independently with sound clinical judgment.

Preferred Skills (Nice to Have):

• Experience conducting pharmacy-related clinical reviews.
• Proven ability to work effectively in a fast-paced, team-oriented environment.
• Excellent verbal and written communication skills.