Arizona Licensed Grievance Nurse

Job Summary

Working remotely on a full-time contract basis, an Arizona Licensed Grievance Nurse will serve as a clinical and administrative subject matter expert for grievance and appeal functions, investigating member and provider appeals while ensuring compliance with CMS requirements.

Key responsibilities

• Investigate and resolve complex grievance and appeal issues, coordinating with members, providers, and other stakeholders
• Maintain a thorough understanding of Health Plan operations, regulatory compliance, and CMS rules related to grievance and appeal processes
• Provide excellent service to internal and external customers by adhering to established policies and demonstrating core behaviors

Required qualifications

• Current, active, unrestricted Licensed Practical Nurse (LPN) license in Arizona
• Associate's Degree in a healthcare field of study or Nursing Diploma
• Five years of experience in CMS member services, prior authorizations, or grievance and appeal functions
• Working knowledge of CMS Managed Care Manual and healthcare billing processes
• Demonstrated ability to evaluate medical records and health plan benefit documents