Remote RN Appeals and Grievances / Quality of Care – CA & Compact

Job Overview

  • Clinical License RN
  • State(s) Compact, CA

Full job description

Active California Nursing License is required.

Compact License not accepted.

Multistate License not accepted.

Duties

  • The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review.
  • Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan.
  • Works with the external providers and Participating Physician Group’s (PPG) representatives to obtain relevant medical records and communication documentation.
  • Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
  • Perform other duties as assigned.

Required:
2 or more years of experience in Clinical Nursing and 2 years in MediCaid in a managed care/ health plan environment.

2 or more years of experience in Clinical Nursing and 2 years in MediCare in a managed care/ health plan environment.

Good working knowledge of regulatory requirements/standards.

Excellent interpersonal and communication skills.

Computer literacy and adaptability to computer learning.

Time management and priority setting skills.

Must be organized and a team player

Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies.

Schedule:

There are 4 schedules available, holidays will be required if they fall on your schedule:

Wednesday – Sunday: 7am-4pm Pacific Time

  • Off days: Monday – Tuesday

Sunday – Thursday: 7am-4pm Pacific Time

  • Off days: Friday – Saturday

Tuesday – Saturday: 7am-4pm Pacific Time

  • Off days: Sunday – Monday

Monday – Friday: 8am – 5pm Pacific Time

  • Off Days: Saturday – Sunday

Licenses/Certifications

Required

  • Registered Nurse (RN) – Active, current and unrestricted California Nursing License

Job Types: Full-time, Contract

Pay: From $50.00 per hour

Expected hours: 40 per week

Schedule:

  • Holidays

Application Question(s):

  • Do you have managed care experience within a health plan?
  • Do you current have an active California Nursing License?
  • Do you have 2 years experience with MediCaid and MediCare?

Work Location: Remote

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