Clinical Nurse, RN or LPN Needed for Grievance & Appeals - New York, New York -

Per Diem Nursing Job in
New York , New York, 10017

  • Employer: Robert Half International
  • Profession: Licensed Practical Nurse
  • Specialty: Administrative / Research / Non-Clinical
  • Compensation: 75.00 - 150.00/hour

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Manhattan based organization is in need of multiple clinical nurses, ideally RN's but open to LPN's to assist with processing comprehensive grievance and appeals requests from members and providers. Appeals Specialist must review and identify through clinical review and system or processing issues that resulted in the failure to provide appropriate care to members. Consulting opportunity is long term and eventually could be work from home. Excellent compensation for highly skilled individuals! Person will be responsible for as follows:
-Conducts investigations and reviews of member and provider medical necessity grievances and appeals;
-Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity;
-Extrapolate and summarize medical information for Medical Director, consultants or other external review;
-Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines;
-Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval;
-Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements;
-Apply expedited criteria to recommend the appropriateness of urgent requests;
-Documents and logs appeal/grievance/dispute information on relevant tracking systems;
-Generates written correspondence to providers, members and regulatory entities;
-Interact with members, providers and/or other staff to ensure resolution of plan recommendations;
-Recognize potential quality of care concerns and refer to the Medical Director for review;
-Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
-Provide client, member and / or provider support to drive resolution of issues that may arise
-Be familiar with business / industry concepts and terminology as pertains to appeals, grievances and claims processing
-Have experience with Medicaid (prefer NY) A&G
-Ensure accurate documentation of all forms of communications received by clients, members and / or providers
-Identify requests for escalation / complaints and escalate accordingly
-Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow - up with the member/provider / facility
-Research complex issues across multiple databases and work with support resources to resolve inquiry independently
-Ensure the correct letter template is utilized when selecting the correct attachments and

Job Requirements

RN or LPN, MD, DDS Prior experience with Appeals & Grievances


New York, New York , 10017

Employment Type

Per Diem


75.00 - 150.00/hour


Robert Half International

Date Posted

Jan 3rd, 2019

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