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UCLA Health

Appeals & Grievances Nurse

UCLA Health, Los Angeles, California, United States, 90079


Description

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.

Salary Range: $61.79-$79.91/hourlyQualifications

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

UCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person’s unique achievements and experiences to further set us apart.