Appeals and Grievances RN - 244847 - Medix : Job Details

Clinical Review Nurse – Remote (CA, AZ, TX, NV)

💰 $52 – $65/hour (DOE)

🕒 Full-time | Monday – Friday | 8am–5pm PST

About the Role

We're seeking an experienced Clinical Review Nurse to lead investigations and reviews of complex member and provider grievances, appeals, and disputes. In this role, you'll assess medical necessity, identify quality-of-care concerns, and ensure timely resolution in compliance with federal, state, and accreditation standards.

This is a remote position for candidates in CA, AZ, TX, or NV (work must be performed from your home IP address).

What You'll Do

• Review and investigate member/provider grievances, appeals, and disputes for medical necessity
• Summarize clinical findings for Medical Director and external reviewers
• Apply clinical guidelines, EOC benefit rules, and policy to case decisions
• Prepare recommendations to uphold or overturn determinations
• Ensure cases are resolved within required timeframes
• Document cases and generate regulatory correspondence
• Identify system/process issues and recommend improvements

Must-Have Qualifications

• Active, unrestricted California RN license
• 2+ years appeals and grievances casework experience
• In-depth knowledge of accreditation standards, state/federal regulations, and managed care
• Medical coding knowledge
• Proficient in Microsoft Office (Word, Excel, Access, Project)

Preferred Skills

• Bachelor's degree in Nursing
• Utilization or Quality Management experience
• Familiarity with MCG, NCQA, and managed care practices

Soft Skills

• Strong analytical and problem-solving abilities
• Excellent verbal/written communication
• Strong case preparation & clinical judgment
• Team-oriented with ability to work independently

📌 Note: Employees cannot travel with work equipment. Work must be completed from home location.

If you're a detail-oriented RN with a passion for ensuring quality care and resolving complex cases, we'd love to hear from you.