What are the responsibilities and job description for the Grievance & Appeals Nurse Specialist - Temp position at Sunshine Enterprise Inc?
Job Description
Grievance & Appeals Nurse Specialist
At Sunshine Enterprise USA, we're not just a company; we're a community of dedicated professionals committed to excellence and innovation. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.
Job Title : Grievance & Appeals Nurse Specialist
Department(s) : Grievance and Appeals Resolution Services (GARS)
Reports to : Manager Clinic Operations, Grievance & Appeals
Salary : $40.87 - $67.82 per hour
Duration : Up to 6 months.
Job Summary
The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. The incumbent will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. The incumbent will clearly articulate the facts and the client's position regarding disputes to the Administrative Law Judge hearing the case. The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.
Position Responsibilities
- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals / priorities for the department.
- Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
- Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
- Presents recommendations based on clinical review, criteria and organizational policies to physician reviewers for final determination.
- Resolves complex and sensitive member issues within established timelines.
- Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
- Analyzes and reports cases through GARS' subcommittee.
- Participates in departmental meetings, trainings and audits as requested.
- Oversees state hearing cases.
- Assists with the notification process to members or providers on the clinical decision issued.
- Discusses appeal process, medical decisions, and hearing rights with members.
- Assists members in coordinating their services with providers and communicates the status and outcome to members.
- Assigns position statements and represents the client at state hearings.
- Completes other projects and duties as assigned.
Possesses the Ability To :
Experience & Education
Preferred Qualifications
Knowledge of :
At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits :
Sunshine Enterprise USA is an "Equal Opportunity Employer-Minorities, Females, Veterans and Disabled Persons"
Salary : $41 - $68
