Arizona Licensed Grievance Nurse

Job Summary

A company is looking for a Grievance and Appeals Nurse (AZ Certified).

Key Responsibilities

• Serve as a subject matter expert for Part C and Part D grievance and appeal functions
• Investigate and resolve member, provider, and claim processing appeals in accordance with CMS requirements
• Coordinate complex grievance and appeal investigations, analyzing documentation to make determinations

Required Qualifications

• Associate degree in nursing (RN), nursing diploma, LPN, RN certification, or BSN
• Experience in Medicare medical necessity appeals and escalations for grievances
• Knowledge of CMS Managed Care Manual Chapter 13 and Prescription Drug Benefit Manual Chapter 18
• Understanding of healthcare billing and claims adjudication processes
• Must be licensed or have a compact license covering the state of Arizona