Nurse RN 4

The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that result from either a preservice, post-service, or claim denial. The Medicare Appeals and Grievances RN will report to the Appeals and Grievances Manager. In this role, you will be responsible for performing first-level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, pharmacy policies, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews may also be performed for medical necessity, non-covered benefits, and to meet the criteria for the coding billed. The ideal candidate will have previous insurance/managed care experience and hold at least a Bachelor's Degree in Nursing. Higher-level certifications are highly desirable.