Job description:
Our client, a large nonprofit hospice and palliative care company is seeking a qualified candidate to join their team. In this role, we are looking for someone who is a Registered Nurse in the state of New York to work in the appeals and grievances department. This is a fantastic opportunity for a registered nurse to work for a nonprofit healthcare company
Pay $56.00 per hour
The job is a full time role with possibility of conversion in 2026.
4 days remote 1 day onsite
Job responsibilities for the Registered Nurse:
· Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal
· Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services.
· Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
· Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas.
· Tracks departments’ compliance with requested action as a component of the Appeals and Grievance and determination process.
· Presents cases to Appeals & Grievances File Review.
· Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing
Qualifications needed for Registered Nurse:
· Graduate of accredited nursing program.
· BSN or equivalent experience required.
· 2 years of managed care or hospital-based utilization/ case management experience
· 2 years minimum of clinical experience
· Licensed Registered Nurse in New York State
· Must be proficient in MS Word, Excel and desktop software knowledge preferred.
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