Appeals & Grievance RN

Utilize National Coverage Determination (NCD), Local Coverage Determination (LCD), Milliman Care Guidelines, and other nationally recognized clinical guidelines such as NCCN and ACOG. This role is responsible for concurrent review of medical records and documentation, determining appropriate outcomes, and ensuring members have quality access to provider care.

Commercial Appeals and Grievance Registered Nurse (RN)




Job Summary

The Commercial Appeals and Grievance RN reviews and processes member-generated pre-service and post-service appeals and grievances. This role is responsible for concurrent review of medical records and documentation, determining appropriate outcomes, and ensuring members have quality access to provider care. The RN collaborates with medical directors, coordinators, and leadership to provide clear, well-rationalized determinations and identify any necessary follow-up actions.

Responsibilities

• Review and process clinical appeals related to pre-service and post-service concerns and complaints from members.
• Conduct accurate, timely first-level reviews in accordance with organizational and regulatory standards.
• Utilize National Coverage Determination (NCD), Local Coverage Determination (LCD), Milliman Care Guidelines, and other nationally recognized clinical guidelines such as NCCN and ACOG.
• Evaluate appeals for benefit coverage, medical necessity, coding accuracy, and compliance with medical policies.
• Collaborate with medical directors, coordinators, and leadership to ensure consistent and compliant decision-making.
• Document clinical rationales and determinations clearly and concisely.
• Identify and communicate any trends, discrepancies, or issues related to clinical determinations or documentation.

Requirements

• Registered Nurse (RN) license in good standing.
• Associate Degree in Nursing (ADN) required;Bachelor of Science in Nursing (BSN) preferred.
• Minimum 2 years of managed care experience, including familiarity with MCG, LCD, and NCD.
• Minimum 2 years of acute or sub-acute clinical experience.
• Knowledge of commercial and Medicare health coverage benefits and review processes.
• Experience with prior authorization, pre-service, and post-service review.
• Proficiency with Excel, Microsoft Office, PDF tools, shared drives, Teams, and SharePoint.

Skills

• Strong knowledge of managed care principles and utilization review processes.
• Ability to interpret and apply clinical guidelines and coverage determinations.
• Excellent written and verbal communication skills for clear clinical rationales.
• High attention to detail in reviewing medical records and documentation.
• Proficient computer and data entry skills across multiple platforms and systems.
• Strong critical thinking and clinical assessment abilities.

Summary Qualification

• Strong understanding of regulatory requirements related to health insurance (e.G., NCQA, CMS, DMHC, DHCS).
• Demonstrated ability to work effectively in a fast-paced, changing environment.
• Ability to work both independently and collaboratively within a team.
• Strong clinical assessment skills and sound professional judgment.
• Ability to recognize discrepancies and inaccuracies in medical determinations and clinical documentation.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.