RN Appeals and Grievances Job at TalentHub Workforce, Inc in New York

Job description:

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 $56.00 per hour

The job is a full time role with possibility of conversion in 2026.

4 days remote 1 day onsite

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.