Job Description
Are you an experienced Nurse RN with a desire to excel? If so, then Talent Software Services may have the job for you! Our client is seeking an experienced Nurse RN to work in CA(Hybrid).
Primary Responsibilities/Accountabilities:
- The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post service or claim denial. The Medicare Appeals and Grievances RN will report to the Appeals and Grievances Manger.
- In this role you will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, pharmacy policies and nationally recognized sources such as MCG, NCCN, and ACOG.
- Reviews may also be performed for medical necessity, non-covered benefits and to meet the criteria for the coding billed. The ideal candidate will have previous insurance/managed care experience and hold at least a Bachelor's Degree in Nursing. Higher-level certifications are highly desirable.
Qualifications:
- Knowledge of Medicare benefits and appeal reviews
- Requires 2-4 years of health insurance or related experience
- Demonstrate the ability to act independently using sound clinical judgement
Preferred:
- Experience with pharmacy clinical reviews
- Works well in a fast-paced team environment
- Excellent communication skills