California Licensed Grievance Nurse

Job Summary

As a California Licensed Grievance Nurse working remotely on a full-time basis, the nurse will manage medical necessity grievances, appeals, and denials by reviewing clinical data, preparing case reviews for the Medical Director, and generating appeal resolution communications in accordance with company policies and NCQA guidelines.

Key responsibilities

• Review clinical information to determine claim payment and manage the appeals process within NCQA timeframes
• Identify quality care concerns and prepare case reviews for the Medical Director when criteria are not met
• Generate appeal resolution communications and assist in developing corrective action plans for quality improvement

Required qualifications

• Current California RN, LPN, or LVN license
• RN with 2+ years or LPN/LVN with 3+ years of clinical nursing experience
• Experience with utilization or appeals review preferred
• Knowledge of InterQual criteria preferred