Grievance And Appeals Nurse

Review information from members, providers, and other interested parties;collect and analyze supporting documentation;and make appropriate grievance and appeal determinations. Clinical or healthcare operations professional with extensive experience handling CMS-related member services, claims, grievances, and appeals.

Grievance and Appeals Clinical and Administrative Specialist


Job Summary

Serves as a clinical and administrative subject matter expert for Part C and Part D grievances and appeals. Investigates member, provider, claim processing, and customer service issues;coordinates timely resolutions;and ensures responses comply with CMS requirements, regulatory standards, and established timelines.

Responsibilities

• Maintain comprehensive knowledge of health plan operations, workflows, system requirements, plan benefits, authorizations, referrals, provider networks, claims, and regulatory compliance.
• Maintain current knowledge of CMS rules and regulations governing grievance and appeal processes.
• Participate in CMS audits and other related activities.
• Coordinate the investigation and resolution of complex grievances and appeals.
• Review information from members, providers, and other interested parties;collect and analyze supporting documentation;and make appropriate grievance and appeal determinations.
• Perform all duties in accordance with organizational policies, procedures, regulatory and accreditation requirements, and professional standards.
• Provide excellent service to internal and external customers while demonstrating strong customer service and leadership behaviors.
• Perform other duties as assigned.

Requirements

• At least five years of experience in CMS member services, prior authorizations, appeals and grievances, or claims functions.
• Associate degree in a healthcare-related field or a nursing diploma.
• Current, active, unrestricted Licensed Practical Nurse or Registered Nurse license.
• Working knowledge of the CMS Managed Care Manual, Chapter 13, and CMS Prescription Drug Benefit Manual, Chapter 18.
• Knowledge of healthcare billing and claims adjudication processes.
• Familiarity with medical terminology and ICD, CPT, HCPCS, and DRG codes.
• Strong interpersonal, written, verbal, mathematical, communication, and business skills.
• Proficiency with common office software and accurate, efficient keyboarding skills.
• Ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.

Skill

• Grievance and appeal investigation
• CMS regulatory compliance
• Medical record and benefit document interpretation
• Claims adjudication and healthcare billing
• Medical terminology and coding knowledge
• Documentation review and analysis
• Customer service and communication
• Critical thinking and decision-making
• Microsoft Office and keyboarding proficiency

Summary Qualification

• Clinical or healthcare operations professional with extensive experience handling CMS-related member services, claims, grievances, and appeals.
• Demonstrated ability to interpret medical records, benefit documents, and regulatory requirements.
• Strong knowledge of Part C and Part D grievance and appeal processes.
• Skilled in managing complex investigations, analyzing documentation, and making accurate determinations.
• Strong customer service orientation with excellent interpersonal and communication skills.
• Preferred qualifications include one to three years of managed care experience and a bachelor s degree in general studies, nursing, or business administration.

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.