Bethlehem, Pennsylvania
Durham, North Carolina
Cheverly, Maryland
Wausau, Wisconsin
Baltimore, Maryland
Durham, North Carolina
Alamogordo, New Mexico
Posted: 17-Jan-25
Location: Los Angeles, California
Categories:
Internal Number: 145779559
As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You will:
- Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with clinical and administrative teams.
- Assessing cases to determine the appropriateness of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies.
- Identifying and investigating Potential Quality Issues (PQIs) to ensure continuous improvement in care delivery.
- Complete other duties as assigned.
We’re seeking a highly qualified candidate with:
• A BSN or MSN degree, required
• Current valid California RN license, required
• Minimum of 2 years’ experience in a managed care or Medicare Advantage setting is highly desired
• Experience in handling appeals, grievances, utilization management, or potential quality issues
• Knowledge of Medicare Advantage plan operations and CMS regulations, highly desired
• Strong clinical assessment and decision-making skills, particularly in evaluating medical necessity
• Thorough understanding of Medicare Advantage regulations, especially related to appeals, grievances, and PQIs, highly desired
• Excellent written and verbal communication skills to communicate complex medical information to members and providers effectively
• Proficiency in Microsoft Office Suite and case management software
