Grievance and Appeals Nurse – Medicare

Position Title: Grievance and Appeals Nurse Work Location: Remote Assignment Duration: 14+ Weeks Work Arrangement: Remote Position Summary: This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines.

Maintains a thorough understanding of our organization operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance. Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes. Participates in CMS and other audits and related activities as required. Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations. Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day. The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned.