Medical Review Registered Nurse – Appeals & Grievance

About the role

The Commercial Appeals and Grievance Registered Nurse conducts first‑level reviews of member‑generated pre‑service and post‑service appeals. Reporting to the Nurse Manager, the RN ensures timely, accurate determinations that align with company policies and regulatory standards.

Key responsibilities

• Review and process appeals related to benefits, medical necessity, coding accuracy, and policy compliance.
• Analyze medical records using National Coverage Determination (NCD), Local Coverage Determination (LCD), Milliman Care, NCCN, and ACOG guidelines.
• Collaborate with medical directors, coordinators, and leadership to provide final determinations with clear rationales.
• Identify discrepancies in clinical documentation and recommend follow‑up actions.
• Maintain compliance with regulatory requirements (NCQA, CMS, DMHC, DHCS).

Required profile

• Registered Nurse (RN) license.
• Associate Degree in Nursing (ADN); Bachelor of Science in Nursing (BSN) preferred.
• Minimum 2 years managed‑care experience (MCG, LCD, NCD knowledge).
• Minimum 2 years acute or sub‑acute clinical experience.
• Familiarity with commercial and Medicare health‑coverage benefits and prior‑authorization processes.

Required skills

• Proficiency with Microsoft Excel.
• Experience using Microsoft Office suite, PDF tools, shared drives, Microsoft Teams, and SharePoint.

What we offer

• Hourly pay range of $42.00–$44.00.
• Overtime eligibility for non‑exempt employees.
• Comprehensive benefits package including medical, dental, vision, 401(k) match, paid time off, and more.