RN Appeals and Grievances
Active RN License for D.C. is required
D.C. is NOT compact or multistate...
Duties
Ā The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review.
Ā Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan.
Ā Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
Ā Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
Ā Perform other duties as assigned.
Required:
2 or more years of experience in Clinical Nursing and 2 years in Medicaid in a managed care/ health plan environment.
Good working knowledge of regulatory requirements/standards.
Excellent interpersonal and communication skills.
Computer literacy and adaptability to computer learning.
Time management and priority setting skills.
Must be organized and a team player
Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies.
Licenses/Certifications
Required
Ā Registered Nurse (RN) - Active, current and unrestricted District of Columbia
Job Types: Full-time, Contract
Pay: $45.00 per hour
Expected hours: 40 per week
Schedule:
Ā 8 hour shift
Ā Monday to Friday
Application Question(s):
Ā Do you have 2 years experience with MediCaid?
Ā Do you have managed care experience within a health plan?
Ā Do you current have an active DC RN License?
Work Location: Remote
Apply Now
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D.C. is NOT compact or multistate...
Duties
Ā The RN will not be processing appeals/grievances traditionally but will be reviewing the appeals/grievances to identify any QOC (Quality of Care) concerns; in turn, any concerns are then sent to an MD for further review.
Ā Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan.
Ā Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
Ā Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
Ā Perform other duties as assigned.
Required:
2 or more years of experience in Clinical Nursing and 2 years in Medicaid in a managed care/ health plan environment.
Good working knowledge of regulatory requirements/standards.
Excellent interpersonal and communication skills.
Computer literacy and adaptability to computer learning.
Time management and priority setting skills.
Must be organized and a team player
Able to work effectively with various internal departments/service areas, health plan partners, participating provider groups, and other external agencies.
Licenses/Certifications
Required
Ā Registered Nurse (RN) - Active, current and unrestricted District of Columbia
Job Types: Full-time, Contract
Pay: $45.00 per hour
Expected hours: 40 per week
Schedule:
Ā 8 hour shift
Ā Monday to Friday
Application Question(s):
Ā Do you have 2 years experience with MediCaid?
Ā Do you have managed care experience within a health plan?
Ā Do you current have an active DC RN License?
Work Location: Remote
Apply Now
For more such jobs please click here!