Clinical Appeal and Grievance Nurse

Clinical Appeal and Grievance Nurse – Magna Care

BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment and reports directly to the Clinical Appeal Manager.

Note:

This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice.

• Independently review and analyze pre- and post-service medical necessity, benefit, and quality-of-care cases using member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines including, but not limited to, inpatient acute, post-acute, outpatient, specialty pharmaceutical, and durable medical equipment.
• Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions.
• Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure.
• Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements.
• Accurately enter case details in the medical management platform.
• Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement.

• Active and unrestricted RN or LPN license; must maintain licensure throughout employment.
• Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting.
• Minimum of 5 years’ clinical experience across various care settings (inpatient acute, SNF/LTAC/ARU, outpatient, DME, complex care).
• Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA.
• Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
• Ability to work independently with exceptional accountability.
• Adaptability to a fast-paced and evolving environment.
• Preferred experience in a Third-Party Administrator (TPA) setting.

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

We are an Equal Opportunity Employer.