Grievance & Appeals Nurse
Core
Review clinical data to determine claim payment, overturn denied claims, and resolve member grievances based on medical necessity criteria and NCQA guidelines.
Role type
Senior IC clinical nurse (utilization review & appeals)
Builds
Appeal resolutions, disposition of denials, and corrective action plans for clinical events
Domain
Healthcare insurance / Utilization management
Required skills
Clinical nursing judgment, NCQA guideline interpretation, medical necessity criteria evaluation, case review preparation, system authorization management, administrative law hearing preparation, policy revision, provider liaison
Preferred skills
Utilization review experience, InterQual criteria knowledge
Technologies
NCQA guidelines, InterQual criteria, appeals turnaround database
Responsibilities
Review clinical information to determine if medical necessity criteria are met, identify potential quality care concerns, prepare case reviews for the Medical Director, generate appeal resolution communications, create system authorization events for overturned denials, gather information for Administrative Law Hearings, assist in revising clinical policies
Seniority
Mid-level, hands-on IC