RN Appeals and Grievances

Active RN License for D.C. is required D.C. is NOT compact or multistate... 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. 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. Licenses/Certifications Required • Registered Nurse (RN) - Active, current and unrestricted District of Columbia Job Types: Full-time, Contract Pay: $45.00 per hour Expected hours: 40 per week Schedule: • 8 hour shift • Monday to Friday Application Question(s): • Do you have 2 years experience with MediCaid? • Do you have managed care experience within a health plan? • Do you current have an active DC RN License? Work Location: Remote Apply Job! For more such jobs please click here!