Grievance & Appeal Specialist (RN)

The Execu|Search Group
Aug 13, 2017
Aug 14, 2017
Employer Type
Direct Employer
Employment Type
Full Time
Job Description:

About the Opportunity A nonprofit healthcare agency in New York City is actively seeking a licensed Registered Nurse (RN) for a promising Grievance & Appeal Specialist position with their growing medical staff. In this role, the Grievance & Appeal Specialist (RN) will be responsible for resolving grievances, appeals and external reviews for one of the agency's product lines. Apply today! Company Description Nonprofit Healthcare Agency Job Description The Grievance & Appeal Specialist (RN) will: * Coordinate efficient functioning of day-to-day operations according to defined processes and procedures * Create and maintain accurate records documenting the actions and rationale for each grievance or appeal decision * Develop and maintains current knowledge of State and Federal regulatory requirements related to all aspects of grievances and appeals for Medicare Managed Care organizations, Medicaid, Home Healthcare, and Managed Long-term Care * Investigate and review routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc. * Collaborate with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal to investigate and facilitate resolution of individual grievances and appeals * Provide input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service * Review information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria * Enter data and assist with compiling reports and analysis on the grievance and appeals process * Participate in special projects and performs other related duties, as needed Required Skills * 3+ years of Healthcare experience; 2+ years of Grievance and Appeals in a Managed Care setting * Bachelor's Degree in Nursing * NYS Registered Nurse (RN) license * Medical and/or Utilization Management background * Computer savvy * Microsoft Office/Suite proficient (Excel, Word, etc.) * Solid problem solving and time management skills * Great interpersonal skills * Excellent communication skills (written and verbal) * Strong attention to detail * Highly organized * Able to multitask efficiently and effectively Desired Skills * Master's Degree in Nursing