Grievance and Appeals Nurse (State)

Facilitate medical necessity grievances, appeals, and denials by reviewing clinical data to determine if criteria are met and claim payments based on NCQA guidelines. Overturn denied claims, uphold denials, and submit cases to the Medical Director for review while identifying quality care concerns. Prepare case reviews for the Medical Director, generate appeal resolution communications, and request additional information from providers to resolve issues. Create system authorization events, maintain appeals processes within prescribed timeframes, and provide input into corrective action plans. Assist the Medical Director with revising policies to satisfy NCQA and contractual requirements. Work PST hours remotely as an RN, LPN, or LVN licensed in California.