Registered Nurse Remote

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The Commercial Appeals and Grievance Registered Nurse (RN) reviews and processes appeals resulting from member-generated pre-service or post-service concerns or complaints. The RN is responsible for reviewing all medical records and documentation concurrently while processing these appeals. The role involves performing accurate and timely first-level reviews according to company and regulatory standards, utilizing National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG. The RN reviews appeals for benefits, medical necessity, coding accuracy, and medical policy compliance. Collaboration with medical directors, coordinators, and leadership is essential to review, process, and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure members have quality access to provider care.

Review and process member-generated appeals and grievances. Ensure accurate and timely first-level reviews according to company and regulatory standards. Utilize NCD, LCD, Milliman Care guidelines, and other recognized sources for review. Assess appeals for benefits, medical necessity, coding accuracy, and policy compliance. Collaborate with medical directors, coordinators, and leadership to provide final determinations. Communicate clear rationales and necessary follow-up actions to ensure quality care access.