RN Appeals and Grievances

Active RN License for D.C. is required

D.C. is NOT compact or multistate...

Duties
?? 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.
?? Conducts intake/triage and appropriate classification of QOC concerns, and makes accurate judgment before sending to the corresponding MD within the health plan.
?? Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
?? Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
?? 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
?? 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:
?? 8 hour shift
?? Monday to Friday

Application Question(s):
?? Do you have 2 years experience with MediCaid?
?? Do you have managed care experience within a health plan?
?? Do you current have an active DC RN License?

Work Location: Remote

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