Sr. Appeals & Grievances Registered Nurse Remote for CA...

Overview: Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Sr. Appeals & Grievances Registered Nurse... ?

Candidate must be authorized to work in USA without requiring sponsorship

* ? ***************************************************************************** ? ** Location: 3300 Zinfandel Dr., Rancho Cordova, CA 95670 (Remote Acceptable) ? ** Duration: 9 months contract w/ possibility of extension or conversion to FTE role Notes: ? Work Hours: 8:00am ? 5:00pm Pacific Time. ? Hybrid role, may allow fully remote work. Description: ? The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. ? The Medi-Cal Appeals and Grievances senior RN will report to the Appeals and Grievances Manager. ? In this role, you will perform accurate and timely clinical review of Member-initiated appeals. ? The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and nationally recognized sources such as NCCN and ACOG. ? The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. ? In this role, you will also perform clinical oversight of all Medi-Cal grievances. ? In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member's clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited. Qualifications: ? Requires a current California RN license. ? Knowledge of Medi-Cal benefits and reviews. ? Requires 2 years of health insurance or related experience. ? Software skills required: MS Office, MS Excel, Email. ? Demonstrate the ability to act independently using sound clinical judgement. Preferred Qualifications (nice to haves): ? Works well in a fast-paced team environment. ? Excellent communication skills. ? ********************************************************************* I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you. Satwinder ?Sat? Singh Lead Technical Recruiter Company Overview: Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients? businesses forward. Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state, and federal laws Apply Job! For more such jobs please click here!