Job Description

Job Title: Registered NurseJob Description The Commercial Appeals and Grievance Registered Nurse (RN) reviews and processes appeals resulting from member-generated pre-service or post-service concerns or complaints. The RN is responsible for reviewing all medical records and documentation concurrently while processing these appeals. The role involves performing accurate and timely first-level reviews according to company and regulatory standards, utilizing National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG. The RN reviews appeals for benefits, medical necessity, coding accuracy, and medical policy compliance. Collaboration with medical directors, coordinators, and leadership is essential to review, process, and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure members have quality access to provider care. Responsibilities + Review and process member-generated appeals and grievances. + Ensure accurate and timely first-level reviews according to company and regulatory standards. + Utilize NCD, LCD, Milliman Care guidelines, and other recognized sources for review. + Assess appeals for benefits, medical necessity, coding accuracy, and policy compliance. + Collaborate with medical directors, coordinators, and leadership to provide final determinations. + Communicate clear rationales and necessary follow-up actions to ensure quality care access. Essential Skills + 1 year of Utilization Review/Management experience + Proficiency in Utilization Management and Utilization Review + Knowledge of MCG and prior authorization processes + Experience in acute and inpatient settings + Proficiency in Microsoft Office Additional Skills & Qualifications + CA RN License + 2+ years of Managed Care experience + 2 years minimum of Acute or Sub-Acute Clinical Experience + Associate Degree of Nursing (ADN) preferred + Bachelor of Science in Nursing (BSN) preferred Work Environment This is a remote position with a work schedule from Monday to Friday, 8:30 am to 5:00 pm. Pay and Benefits The pay range for this position is $45.00 - $55.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on May 21, 2025. About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.

Job Tags

Temporary work, Local area, Remote job, Monday to Friday,

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