Registered Nurse

Position Overview

The Appeals & Grievances RN is responsible for reviewing denied cases, evaluating medical necessity, and supporting the resolution of member appeals. This role involves clinical analysis, provider communication, and collaboration with internal committees to ensure accurate, timely, and compliant decision-making.

Key Responsibilities

• Conduct clinical reviews of denied services to determine medical necessity and eligibility
• Analyze medical records and identify gaps in documentation
• Contact provider offices to obtain additional clinical information as needed
• Present case findings and recommendations to the Appeals & Grievances Committee
• Draft clear, compliant resolution letters in accordance with regulatory requirements
• Ensure all reviews and documentation meet organizational and compliance standards

Required Qualifications

• Active Registered Nurse (RN) license
• Experience in health plan operations, Appeals & Grievances, Utilization Management, or Quality
• Strong clinical judgment and analytical skills
• Proficiency with EMR systems and medical documentation review
• Excellent written and verbal communication skills

Preferred Qualifications

• Bachelor’s degree in Nursing (BSN)
• Familiarity with Medicaid and/or CMS guidelines

Key Competencies

• Ability to communicate effectively with both providers and patients/families
• Strong attention to detail and organizational skills
• Emotional intelligence and professionalism in sensitive situations
• Collaborative, solutions-oriented mindset

What This Role Offers

• Consistent weekday schedule with no overtime
• Hybrid work environment
• Supportive and collaborative team culture
• Opportunity for long-term placement based on performance
• Direct impact on patient care through the appeals process