Remote Grievance and Appeals Nurse

Details for the position are as follows:7-month contract to start with the possibility of extension or conversion depending on performance and business needsRate: $43.51100% remote but must have a valid Arizona nursing license or a compact license allowing you to practice in the state of ArizonaMust be able to support Arizona hours. Job Description:This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines. Maintains a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance. Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes. Participates in CMS and other audits and related activities as required. Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations. Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day. The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Required Skills:Associates degreeRN or LPN background Experience with Prior authorizations or Appeal and grievances is highly preferredBy applying for this job, you agree to receive calls, AI-generated calls, text messages, or emails from and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy at Privacy Policy