Job Description

Hiring a Registered Nurse for a great healthcare company in CA - Fully Remote! Must have CA License, managed care experience, and at least Acute or Sub-Acute clinical experience! Appeals & Grievances Location: Remote (No travel required) Schedule: Monday-Friday, 8:30 AM - 5:00 PM (40 hours/week) Position Summary: We are seeking four experienced and detail-oriented Registered Nurses (RNs) to join the Appeals and Grievances team. In this role, you will be responsible for reviewing and processing member-generated pre-service and post-service appeals. You will collaborate with internal stakeholders to ensure timely, accurate, and regulatory-compliant determinations that support quality access to care. Key Responsibilities: + Conduct first-level clinical reviews of appeals and grievances in accordance with regulatory and organizational standards. + Analyze medical records and documentation to determine medical necessity, benefit coverage, and policy compliance. + Apply clinical guidelines including Milliman Care Guidelines (MCG), National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and other nationally recognized standards (e.g., NCCN, ACOG). + Collaborate with medical directors, coordinators, and leadership to finalize determinations and ensure appropriate follow-up actions. + Maintain accurate documentation and provide clear rationale for decisions. Required Qualifications: + Licensure: Active Registered Nurse (RN) license in the state of California. + Education: Associate Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred. + Experience: + Minimum 2 years of Managed Care experience, including familiarity with MCG, LCD, and NCD. + Minimum 2 years of Acute or Sub-Acute clinical experience. + Skills: + Strong clinical assessment and documentation review skills. + Ability to work independently and collaboratively in a fast-paced, evolving environment. + Excellent communication and critical thinking abilities. Preferred Qualifications: + Experience with Commercial and Medicare health coverage benefits, including prior authorization and service reviews. + Familiarity with regulatory requirements (NCQA, CMS, DMHC, DHCS). + Case management experience is a plus. Technical Requirements: + Proficiency in Microsoft Office Suite (Excel, Word), PDF tools, Microsoft Teams, SharePoint, and shared drives. + Standard laptop equipment will be provided. Team & Work Environment: + Join a team of 13 professionals at varying levels of experience. + Collaborate with cross-functional teams including Medical Directors, Customer Service, Pharmacy, and Utilization Management. + Remote work setup; no VDI or Ethernet cord required. Interview Process: + Format: Web conference (Zoom or Microsoft Teams) + Structure: One panel interview + Video Required: Yes Target Start Date: June 16, 2025 Pay and Benefits The pay range for this position is $35.00 - $45.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on May 30, 2025. About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.

Job Tags

Temporary work, Work at office, Local area, Remote work, Monday to Friday,

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