About the Opportunity
A New Jersey based company seeks an Appeals/Grievances Registered Nurse to help ensure quality care for patients. Here is an excellent opportunity for a hands-on professional who has management experience and knowledge of the appeals and grievances process to work for a leading managed care organization. It is essential for you to apply nursing process and systems theory to problem solving activities. Do you want the opportunity to work from home a few days a week? Do you want to take your nursing career to the next level? Apply now for immediate consideration.
Company Description
Leading managed care organization
Job Description
Responsibilities for the Appeals/Grievances- NJ Work from Home include:
* Implementing, maintaining and monitoring the basic functions of the Appeals and Grievances Department
* Participating in a leadership role in the department, within company and with our providers
* Overseeing the provision of the basic Appeals and Grievances
* Entering all appeals and grievances in the Unit’s software tracking system
* Ensuring appeals and grievances are categorized and processed within New York State and Federal timeframes
* Receiving, investigating and responding, to member appeal and grievances from all lines of business
* Identifying potential quality issues and initiating referrals to the Quality Improvement Department
* Maintaining absolute file integrity with regards to content, location and confidentiality
* Preparing for and participate in regulatory site visits
* Monitoring quality of records through monthly audits
* Developing reports necessary to monitor/ track operational efficiency and effectiveness
* Analyzing reports (both operational and analytical), and process and case outcome data to implement changes
* Implementing, monitoring and changing as necessary new operational activities and/or programs to enhance performance
* Handling ad hoc requests
# Required Skills: 5+ years of experience in claims or Appeals and Grievance experience
# Valid NJ RN license
# Knowledge of UM / QM & case philosophies
# Knowledge of and experience with quality improvement methodologies
# Excellent decision making abilities and judgment
Apply Now
A New Jersey based company seeks an Appeals/Grievances Registered Nurse to help ensure quality care for patients. Here is an excellent opportunity for a hands-on professional who has management experience and knowledge of the appeals and grievances process to work for a leading managed care organization. It is essential for you to apply nursing process and systems theory to problem solving activities. Do you want the opportunity to work from home a few days a week? Do you want to take your nursing career to the next level? Apply now for immediate consideration.
Company Description
Leading managed care organization
Job Description
Responsibilities for the Appeals/Grievances- NJ Work from Home include:
* Implementing, maintaining and monitoring the basic functions of the Appeals and Grievances Department
* Participating in a leadership role in the department, within company and with our providers
* Overseeing the provision of the basic Appeals and Grievances
* Entering all appeals and grievances in the Unit’s software tracking system
* Ensuring appeals and grievances are categorized and processed within New York State and Federal timeframes
* Receiving, investigating and responding, to member appeal and grievances from all lines of business
* Identifying potential quality issues and initiating referrals to the Quality Improvement Department
* Maintaining absolute file integrity with regards to content, location and confidentiality
* Preparing for and participate in regulatory site visits
* Monitoring quality of records through monthly audits
* Developing reports necessary to monitor/ track operational efficiency and effectiveness
* Analyzing reports (both operational and analytical), and process and case outcome data to implement changes
* Implementing, monitoring and changing as necessary new operational activities and/or programs to enhance performance
* Handling ad hoc requests
# Required Skills: 5+ years of experience in claims or Appeals and Grievance experience
# Valid NJ RN license
# Knowledge of UM / QM & case philosophies
# Knowledge of and experience with quality improvement methodologies
# Excellent decision making abilities and judgment
Apply Now
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