Appeals and Grievance RN Job Summary The Appeals and Grievance RN is responsible for reviewing and processing appeals... accurate final determinations. Responsibilities Review and process member appeals related to pre-service and post-service...
to appropriate care for members with urgent needs Provide referrals to Case Management, Disease Management, Appeals and Grievance... of business or for a specific line of business such as Medicare and FEP. Successful RN candidate reviews prior auth requests...
) and Appeals and Grievance department (AGD) Recognize the client’s right to self-determination as it relates to the ethical.... Education/Experience: Requires a current CA RN License. Bachelor of Science in Nursing or advanced degree preferred Certified...
and intervenes or as clinically appropriate Provides referrals to Case Management, Disease Management, Appeals and Grievance... with other claims and appeals departments to ensure providers are paid appropriately and members receive quality care...