California Licensed Grievance Nurse
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Job Summary
To facilitate medical necessity grievances and appeals, the full-time California Licensed Grievance Nurse will review clinical data, manage denial notifications, and prepare case reviews for the Medical Director while working remotely on PST hours.
Key responsibilities
- Review clinical data to determine claim payment based on company policies and NCQA guidelines
- Prepare case reviews for the Medical Director when criteria are not met and identify quality care concerns
- Generate appeal resolution communications to members and providers in accordance with company policies
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
Complete Job Description
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