Appeals and Grievance RN **REMOTE in CA**

Our client, a provider of Health, Dental, Vision, Medicaid and Medicare Healthcare service plans in the state of California with 4.7 million members and $22.9 billion of annual revenues, seeks an accomplished Appeals and Grievance RN Position: Appeals and Grievance RN Location: REMOTE in CA Duration: 6+ Months Contract with possible extension Pay Rate: $55/hr - $60/hr (depending on experience) Relocation Expenses/ Assistance: NO Position Summary: The Commercial Appeals and Grievance RN is responsible for conducting thorough reviews of member-generated appeals related to pre-service and post-service concerns or complaints. The role requires real-time analysis of medical records and clinical documentation to make timely and accurate first-level determinations based on clinical and regulatory standards. The RN uses established guidelines—such as National Coverage Determination (NCD), Local Coverage Determination (LCD), Milliman Care Guidelines (MCG), NCCN, and ACOG—to evaluate appeals regarding benefits, medical necessity, coding accuracy, and policy compliance. This role involves close collaboration with medical directors, clinical coordinators, and leadership to ensure appropriate outcomes and continued access to quality care for members.

Perform first-level clinical appeal reviews for pre-service and post-service cases. Evaluate cases for medical necessity, coding accuracy, and benefit eligibility using recognized clinical guidelines. Ensure determinations meet internal and external regulatory requirements (NCQA, CMS, DMHC, DHCS). Prepare clear, well-supported rationales for appeal outcomes. Collaborate with interdisciplinary teams including Medical Directors and internal leadership. Utilize digital tools and systems including Microsoft Excel, PDF, Shared Drives, Microsoft Teams, and SharePoint.