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A&G RN Coordinator

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MJHS

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Location:
United States , New York

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Category:
Nursing

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Contract Type:
Not provided

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Salary:

110000.00 - 120000.00 USD / Year
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Job Description:

The RN Coordinator will investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for Medicare & Medicaid Services), and DOH (Department of Health) regulations.

Job Responsibility:

  • Investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for Medicare & Medicaid Services), and DOH (Department of Health) regulations
  • Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal
  • Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services
  • Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations
  • Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas
  • Tracks departments’ compliance with requested action as a component of the Appeals and Grievances determination process
  • Presents cases to Appeals & Grievances File Review
  • Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing as required

Requirements:

  • Graduate of accredited nursing program
  • BSN preferred
  • 2 years managed care or hospital based utilization/case management experience
  • 2 years minimum clinical experience
  • Licensed nurse in New York State
  • Proficiency with Microsoft Word, Excel, Power Point and Outlook is required
  • Must have excellent written and verbal communication skills
  • Must be comfortable researching current evidence based practice guidelines and protocols
  • Must be able to multi-task and managed multiple projects efficiently, meet deadlines, demonstrate analytical/critical thinking skills, and provide excellent customer services that leads to positive problem resolution
What we offer:
  • Sign-on Bonuses OR Student Loan Assistance for clinical staff
  • FREE Online RN to BSN and MSN degree programs
  • Tuition Reimbursement for all full and part-time staff
  • Dependent Tuition Reimbursement for clinical staff
  • Generous paid time off, including your birthday
  • Affordable and comprehensive medical, dental and vision coverage for employee and family members
  • Two retirement plans! 403(b) AND Employer Paid Pension
  • Flexible spending

Additional Information:

Job Posted:
March 04, 2026

Employment Type:
Fulltime
Work Type:
On-site work
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