A&G RN Coordinator Job at MJHS (New York)

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

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A&G RN Coordinator

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