Appeals & Grievances Nurse Specialist RN

Employer Industry: Health Insurance Why consider this job opportunity... - Opportunity for career advancement and growth within the organization - Competitive pay and benefits package - Remote work flexibility - Supportive and collaborative work environment - Chance to make a positive impact on member satisfaction What to Expect (Job Responsibilities): - Conduct intake/triage and appropriate classification of Clinical A&G and Pharmacy requests - Investigate and resolve clinical member complaints and provider disputes - Identify expedited cases and ensure resolution within 72 hours - Work with external providers to obtain relevant medical records and communication documentation - Prepare authorizations after approval by the Medical Director What is Required (Qualifications): - Associate's Degree in Nursing - At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment - Good working knowledge of regulatory requirements/standards - Excellent interpersonal and communication skills - Registered Nurse (RN) - Active, current, and unrestricted California License How to Stand Out (Preferred Qualifications): - Bachelor's Degree in Nursing - Experience in appeals and grievances in a healthcare setting At Talentify, we prioritize candidate privacy and champion equal-opportunity employment. Central to our mission is our partnership with companies that share this commitment. We aim to foster a fair, transparent, and secure hiring environment for all. If you encounter any employer not adhering to these principles, please bring it to our attention immediately. Talentify is not the EOR (Employer of Record) for this position. Our role in this specific opportunity is to connect outstanding candidates with a top-tier employer Apply Job! For more such jobs please click here!