Join our dynamic and patient-focused team at Workwarp as a Clinical Appeals & Grievance Specialist – Registered Nurse (RN)! This pivotal role offers a rewarding opportunity to leverage your clinical expertise and advocacy skills to ensure equitable and timely resolutions for our members. We are seeking a highly motivated and compassionate RN to navigate complex clinical appeals and grievance processes within a hybrid work environment, blending the flexibility of remote work with collaborative engagement in our Remote office. This position is a key contributor to member satisfaction and organizational success, demanding a strong blend of clinical acumen, analytical thinking, and exceptional communication abilities. We offer a competitive salary and comprehensive benefits package commensurate with experience and qualifications.
Why Choose Workwarp?
- Career Advancement & Growth: We are committed to fostering internal talent and providing pathways for professional development. This role offers significant opportunities to expand your skills and advance your career within a growing organization.
- Competitive Compensation & Benefits: We offer a comprehensive and competitive compensation package, including health insurance, retirement plans, paid time off, and other benefits designed to support your well-being.
- Flexible Work Environment: Enjoy the benefits of a hybrid work model, combining the focused environment of remote work with opportunities for in-person collaboration and team building.
- Supportive & Collaborative Culture: We cultivate a positive and supportive work environment where teamwork, open communication, and mutual respect are highly valued.
- Make a Real Difference: You will directly contribute to improving member satisfaction and ensuring fair and just outcomes for our members.
What You'll Do (Key Responsibilities):
- Intake & Triage: Professionally receive and evaluate incoming clinical appeals, grievances, and pharmacy-related requests, ensuring accurate classification and prioritization based on established protocols. This includes conducting initial assessments to determine the nature and urgency of each case.
- Clinical Investigation & Resolution: Thoroughly investigate clinical member complaints and provider disputes, utilizing your clinical expertise and knowledge of medical standards to gather relevant information and identify potential solutions. This involves reviewing medical records, communicating with stakeholders, and analyzing clinical data.
- Expedited Case Management: Identify cases requiring expedited review and resolution, ensuring timely action within strict deadlines (target of 72 hours). Proactively manage high-priority cases to minimize delays and ensure member satisfaction.
- Medical Record Review & Communication: Collaborate with external providers, members, and internal teams to obtain necessary medical records, communication documentation, and supporting information required for thorough case analysis. Maintain accurate and organized case documentation.
- Authorization & Approval Support: Prepare necessary authorizations and supporting documentation for appeals and grievances, ensuring accuracy and completeness before submission for approval by the Medical Director. Follow up on approvals and communicate outcomes to relevant parties.
- Policy Interpretation & Application: Apply your understanding of healthcare regulations, managed care policies, and organizational guidelines to ensure consistent and compliant handling of appeals and grievances.
- Documentation & Reporting: Maintain detailed and accurate records of all case activities, findings, and resolutions. Contribute to reporting and analysis efforts to identify trends and improve processes.
- Stakeholder Communication: Effectively communicate with members, providers, and internal stakeholders regarding the status of appeals and grievances, providing clear and concise updates.
- Process Improvement: Identify opportunities to improve the efficiency and effectiveness of the appeals and grievance process. Contribute to the development and implementation of process improvements.
What You'll Need (Qualifications):
- Education: Associate's Degree in Nursing (ADN) required; Bachelor's Degree in Nursing (BSN) preferred.
- Experience: Minimum of 5-7 years of clinical nursing experience, with at least 2 years specifically in Medicare/Medicaid within a managed care or health plan environment.
- Knowledge: Solid understanding of regulatory requirements, healthcare standards, and managed care principles.
- Skills: Exceptional interpersonal, communication (written and verbal), and problem-solving skills. Ability to navigate complex situations with empathy and professionalism.
- Licensure: Active, current, and unrestricted Registered Nurse (RN) license in the State of California.
- Technical Skills: Proficient in using computer systems, including electronic health records (EHR) and Microsoft Office Suite.
What Will Make You Stand Out (Preferred Qualifications):
- Bachelor's Degree in Nursing (BSN)
- Direct experience in appeals and grievance processes within a healthcare setting.
- Experience with specific healthcare software or systems used for appeals and grievances.
- Certification in healthcare quality or patient advocacy.
Our Commitment to Equity & Inclusion:
At Workwarp, we are deeply committed to candidate privacy and championing equal employment opportunities. We partner with organizations that share this commitment and strive to create a fair, transparent, and secure hiring environment for all. We are dedicated to fostering a diverse and inclusive workplace where everyone feels valued and respected. If you believe you have encountered any employer not adhering to these principles, please bring it to our attention immediately.
Important Note: Workwarp is not the Employer of Record (EOR) for this position. We are a talent solutions provider connecting exceptional candidates with top-tier employers. Apply Now for more information and to submit your application. For additional opportunities, click here.
Ready to join our team and make a difference? We encourage you to apply now! We are excited to review your application and discuss how your skills and experience can contribute to our success.