Appeals & Grievance Nurse Analyst
New
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 3 years
- Required Skills
- Microsoft Office
Requirements
- Registered Nurse (RN) with active license in Tennessee or compact state.
- 3 years clinical nursing experience.
- Proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint).
- Ability to work independently or in a team environment.
- Excellent oral and written communication skills.
- Strong interpersonal and organizational skills.
- Ability to handle multiple projects.
- Experience with appeals and grievance processes.
- Knowledge of Medicare, CMS, and TennCare regulations.
- Experience or interest in AI tools such as Copilot.
Responsibilities
- Ensure timeliness and quality met per regulations/guidelines.
- Utilize multiple systems to research and document validity of appeals or QOC grievances.
- Evaluate and research medical necessity documentation including complex situations.
- Conduct clinical information outreach and prepare case files for Medical Director review.
- Create detailed member and provider specific appeal and QOC grievance response letters.
- Assess response letters for accuracy and compliance and provide recommendations.
- Collaborate with clinical and non-clinical staff for case resolution.
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