Appeals And Grievances Registered Nurse

Job Title: Appeals and Grievances Registered Nurse

Job Description

We are seeking a skilled professional to join our team and handle member appeals and grievances related to healthcare services. This role involves managing both pre-service and post-service concerns, reviewing medical records and documentation to evaluate appeals, conducting timely and accurate first-level clinical reviews using guidelines such as NCD, LCD, Milliman, NCCN, and ACOG, and assessing appeals for benefit coverage, medical necessity, coding accuracy, and policy compliance. You will collaborate with medical directors and internal teams to make final determinations, ensuring members receive appropriate care. This position reports directly to the Nurse Manager and plays a key role in providing fair and quality access to healthcare services for our members.

Responsibilities

• Handle member appeals and grievances related to healthcare services.
• Review medical records and documentation to evaluate appeals.
• Conduct first-level clinical reviews using guidelines such as NCD, LCD, Milliman, NCCN, and ACOG.
• Assess appeals for benefit coverage, medical necessity, coding accuracy, and policy compliance.
• Collaborate with medical directors and internal teams to make final determinations.
• Ensure members receive appropriate care.

Essential Skills

• Managed Care Experience (MCG, LCD, and NCD knowledge) – 2 years minimum.
• Acute or Sub-Acute Clinical Experience – 2 years minimum.
• Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews.
• Experience with prior authorization, pre-service and post-service review, appeals, utilization management, utilization review, and case management.

Additional Skills & Qualifications

• Strong understanding of regulatory requirements pertaining to health insurance (NCQA, CMS, DMHC, DHCS).
• Proficiency in Excel, Microsoft, PDF, Shared drive, and medical records review.
• Ability to work in a fast-paced and changing environment.
• Strong communication skills.
• Ability to work independently and in a team setting.
• Strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation.

Work Environment

This is a fully remote opportunity that requires residency in California. The work schedule is Monday through Friday, 8am to 5pm, with a 1-hour lunch break. This position offers the chance to gain experience with a large health plan while working in a dynamic environment.

Job Type & Location

This is a Contract position based out of Rancho Cordova, California.

Pay and Benefits

The pay range for this position is $50.00 - $56.00/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 hybrid position in Sacramento,CA.

Application Deadline

This position is anticipated to close on Oct 7, 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 for other accommodation options.

Salary : $50 - $56