Sample Job Description for Grievance and Appeals Resolution Nurse
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Grievance and Appeals Resolution Nurse Job Overview
Grievance and Appeals Resolution Nurse Job Description Sample
Conducts the medical review activities needed to resolve and process clinical appeals and claims.
JOB LEVEL
P03
EDUCATION/DEGREE
Bachelor's Degree
REPORTS TO
Manager
Salary Range
BASE 50%
$90,900
TOTAL 50%
$96,000
Job Responsibilities for Grievance and Appeals Resolution Nurse
Reviews applicable medical records and assesses clinical data to investigate and resolve disputes over the medical necessity for services, approvals, pre-certifications, or other cases. Understands and interprets applicable medical terminology, clinical procedures, regulations and policies. Documents cases according to guidelines and standard procedures. Prepares the documentation required for further medical review, hearings, and different appeal processes.
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| 1 | Nursing Talent Acquisition Specialist | The Nursing Talent Acquisition Specialist places advertisements, attends job fairs, and heads in-house recruitment efforts. Recruits qualified applicants for licensed practical nurses, graduate nurse positions, or positions requiring registered nurse licensure. Being a Nursing Talent Acquisition Specialist may require a bachelor's degree. Interviews candidates and refers them to the appropriate clinical service. In addition, Nursing Talent Acquisition Specialist typically reports to a manager. May require RN license. Being a Nursing Talent Acquisition Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. Working as a Nursing Talent Acquisition Specialist typically requires 2 to 4 years of related experience. |
| 2 | Grievance and Appeals Resolution Manager | The Grievance and Appeals Resolution Manager oversees research, investigation, negotiation and resolution of all types of appeals and grievances. Plans, organizes, and directs the work activity of the appeal and grievance team consistent with organizational policies and procedures and which is compliant with state and federal guidelines. Being a Grievance and Appeals Resolution Manager requires a bachelor's degree. Prepares formal briefs and appears at hearings as a representative of the organization. In addition, Grievance and Appeals Resolution Manager typically reports to a manager or head of a unit/department. The Grievance and Appeals Resolution Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. Working as a Grievance and Appeals Resolution Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. |
| 3 | Grievance and Appeals Resolution Specialist | The Grievance and Appeals Resolution Specialist contacts customers to gather information and communicate disposition of case. Logs, tracks, and processes appeals and grievances. Being a Grievance and Appeals Resolution Specialist builds case files for each grievance and ensures compliance with organizational and regulatory guidelines. Conducts pertinent research in order to evaluate, respond to, and close appeals. In addition, Grievance and Appeals Resolution Specialist requires a bachelor's degree. Typically reports to a supervisor or manager. Being a Grievance and Appeals Resolution Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. Working as a Grievance and Appeals Resolution Specialist typically requires 2 to 4 years of related experience. |
| 4 | Grievance and Appeals Resolution Supervisor | The Grievance and Appeals Resolution Supervisor monitors the research, investigation, negotiation and resolution of all types of appeals and grievances. Supervises a team responsible for review of appeals and grievances to ensure the resolutions are legal and follow company guidelines and procedures. Being a Grievance and Appeals Resolution Supervisor typically reports to a manager or head of a unit/department. Requires a bachelor's degree. The Grievance and Appeals Resolution Supervisor supervises a small group of para-professional staff in an organization characterized by highly transactional or repetitive processes. Contributes to the development of processes and procedures. Thorough knowledge of functional area under supervision. Working as a Grievance and Appeals Resolution Supervisor typically requires 3 years experience in the related area as an individual contributor. |
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Grievance and Appeals Resolution Nurse Skills & Proficiency Level
| Skills | Proficiency Level |
|---|---|
| Standard Operating Procedures (SOP) | Level 3 |
| Attention to Detail | Level 3 |
| Time Management | Level 3 |
