| Grievance & Appeals Nurse - LPN/RN
Grievance & Appeals Nurse - LPN/RN |
Grievance & Appeals Nurse - LPN/RN |
<p class="MsoNormal" style="margin-bottom:0in"><span style="font-family: Calibri, sans-serif; font-size: 11pt;">We are seeking adetail-oriented and experienced Grievance & Appeals Nurse (LPN or RN) tojoin our team in Phoenix, AZ. This role is responsible for reviewing,analyzing, and processing member grievances and appeals in compliance with CMSregulations and organizational policies. The ideal candidate brings strongclinical judgment, regulatory knowledge, and a commitment to delivering fairand timely benefit determinations.</span></p><p class="MsoNormal" style="margin-bottom:0in"><br></p><p class="MsoNormal" style="margin-bottom:0in"><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">The Grievance & AppealsNurse plays a critical role in ensuring regulatory compliance and membersatisfaction by evaluating clinical and non-clinical appeals and grievances.This position requires the ability to interpret medical records, apply benefitplan criteria, and ensure decisions align with CMS guidelines.<o:p></o:p></span></p><p class="MsoNormal" style="margin-bottom:0in"><br></p><p class="MsoNormal" style="margin-bottom:0in"><b><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Schedule:<o:p></o:p></span></b></p><p class="MsoNormal" style="margin-bottom:0in"><ul><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Full-time, 40 hours per week</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Additional hours as neededto meet operational demands</span></li></ul></p><p class="MsoNormal" style="margin-bottom:0in"><b><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Key Responsibilities:<o:p></o:p></span></b></p><p class="MsoNormal" style="margin-bottom:0in"><ul><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Working knowledge of CMSManaged Care Manual Chapter 13 (Beneficiary Grievances, OrganizationDeterminations, and Appeals) and CMS Prescription Drug Benefit Manual Chapter18 (Part D Enrollee Grievances, Coverage Determinations, and Appeals)</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Knowledge of healthcarebilling and claims adjudication processes</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Familiarity with medicalterminology, ICD, CPT, HCPCS, and DRG coding systems</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Strong keyboarding andproficiency with standard office software applications</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Solid math, communication,and business skills</span></li></ul></p><p class="MsoNormal" style="margin-bottom:0in"><b><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Requirements:<o:p></o:p></span></b></p><p class="MsoNormal" style="margin-bottom:0in"><ul><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Associate’s Degree in ahealthcare-related field or Nursing Diploma</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Active, current, andunrestricted LPN or RN license in the state of Arizona</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Minimum of 5 years ofexperience in CMS-related member services, prior authorizations, appeals andgrievances, or claims processing</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Preferred Qualifications</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">1–3 years of experience in amanaged care environment</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Bachelor’s degree innursing, business administration, or a related field</span></li></ul></p><p class="MsoNormal" style="margin-bottom:0in"><b><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Compensation & Benefits:<o:p></o:p></span></b></p><p class="MsoNormal" style="margin-bottom:0in"><ul><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Competitive compensationpackage</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Comprehensive benefitsincluding medical, dental, and vision insurance</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Retirement savings plan</span></li><li><span style="font-size:11.0pt;line-height:115%;font-family:"Calibri",sans-serif">Paid time off</span></li></ul></p> |