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RN Manager, A&G Clinical Review

Req #: 107712
Job Location(s): Brooklyn, NY
Zip Code: 11220
Category: Management - Clinical
Agency:
Status: Regular Full-Time
Office: office-based

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Responsibilities:

Responsible for direct oversight and management of clinical review processes within Appeals & Grievances Department. Ensures regulatory compliance and timely processing for the Medicare and Medicaid appeal and grievance processes, quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or clinical quality. Acts as subject matter expert to internal departments and delegated vendors to assure all are educated and complaint with requirements of appeals and grievance regulations and processing

Qualifications:

  • Bachelor’s Degree required. Master’s preferred
  • 5 plus years’ experience in managed care including appeals and grievance and/or compliance
  • 2 years’ prior supervisory or management experience required
  • Strong knowledge of federal, state and managed healthcare regulations and requirements
  • NYS RN License Degree. Strong leadership skills
  • Detail oriented. Excellent computer software skills including Microsoft Office, Access, PowerPoint, MS Project

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