Registered Nurse for A&G department

Our client, a large nonprofit hospice and palliative care company is seeking a qualified candidate to join their team. In this role, we are looking for someone who is a Registered Nurse in the state of New York to work in the appeals and grievances department. This is a fantastic opportunity for a registered nurse to work for a nonprofit healthcare company

Pay: 45-50 per hour BOE

Schedule: Monday-Friday 9am to 5pm

Hybrid- 1 day onsite and 4 days remote

Job responsibilities for the Registered Nurse:

Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal

Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services.

Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.

Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas.

Tracks departments’ compliance with requested action as a component of the Appeals and Grievance and determination process.

Presents cases to Appeals & Grievances File Review.

Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing

Qualifications needed for Registered Nurse:

Graduate of accredited nursing program.

BSN or equivalent experience required.

2 years of managed care or hospital-based utilization/ case management experience

2 years minimum of clinical experience

Licensed Registered Nurse in New York State

Must be proficient in MS Word, Excel and desktop software knowledge preferred.