Arizona Licensed Grievance Nurse

Job Summary

To support a top healthcare company, the full-time Arizona Licensed Grievance Nurse will manage grievance and appeal functions remotely, ensuring compliance with CMS requirements while investigating member and provider issues.

Key responsibilities

• Investigate and resolve complex grievance and appeal cases, ensuring timely responses in accordance with CMS regulations
• Maintain knowledge of health plan operations, benefits, and regulatory compliance related to grievance and appeal processes
• Coordinate audits and participate in related activities while providing excellent service to internal and external customers

Required qualifications

• Current, active, unrestricted Registered Nurse license in Arizona
• Associate's Degree in a healthcare field or Nursing Diploma
• Five years of experience in CMS member services, prior authorizations, or claims functions
• Working knowledge of CMS Managed Care Manual and healthcare billing processes
• Ability to evaluate medical records and health plan documents for benefit determinations