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Grievance & Appeals Nurse (7024176)

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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


* 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. Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
* Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations
* Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
* Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
* Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
* Gather and prepare case information for Administrative Law Hearings
* Maintain appeals process within the prescribed NCQA time frames and appeals turnaround database
* Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
* May act as liaison between the provider and business to resolve issues

Pay - $36-40/hr

Schedule: M-F (Day shift with flexible start time)

NOT A REMOTE OPPORTUNITY

email resume or call 916-380-3685










About Aerotek:

We know that a company's success starts with its employees. We also know that an individual's success starts with the right career opportunity. As a Best of Staffing Client and Talent leader, Aerotek's people-focused approach yields competitive advantage for our clients and rewarding careers for our contract employees. Since 1983, Aerotek has grown to become a leader in recruiting and staffing services. With more than 250 non-franchised offices, Aerotek's 8,000 internal employees serve more than 300,000 contract employees and 18,000 clients every year. Aerotek is an Allegis Group company, the global leader in talent solutions. Learn more at Aerotek.com.


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