Appeals & Grievances Nurse

As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You will:

• Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with clinical and administrative teams.
• Assessing cases to determine the appropriateness of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies.
• Identifying and investigating Potential Quality Issues (PQIs) to ensure continuous improvement in care delivery.
• Complete other duties as assigned.

We're seeking a highly qualified candidate with:

*A BSN or MSN degree, required

*Current valid California RN license, required

*Minimum of 2 years' experience in a managed care or Medicare Advantage setting is highly desired

*Experience in handling appeals, grievances, utilization management, or potential quality issues

*Knowledge of Medicare Advantage plan operations and CMS regulations, highly desired

*Strong clinical assessment and decision-making skills, particularly in evaluating medical necessity

*Thorough understanding of Medicare Advantage regulations, especially related to appeals, grievances, and PQIs, highly desired

*Excellent written and verbal communication skills to communicate complex medical information to members and providers effectively

*Proficiency in Microsoft Office Suite and case management software