Grievance & Appeals Nurse

Position Purpose: Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Key Details : Candidate must hold California RN Licensure. This position is remote and will work PST hours. Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue cases.…