Sr. Appeals & Grievances Registered Nurse – Remote for CA - Medi-Cal Member Appeals and Grievances Team

Join Our Team: Sr. Appeals & Grievances Registered Nurse – Remote for CA Amerit Consulting is excited to announce a new opportunity for a Sr. Appeals & Grievances Registered Nurse to join our team remotely in California! As a leader in staffing and consulting services, we are dedicated to providing exceptional support to our clients and employees. This role offers a unique blend of remote work and collaboration with our dynamic team. If you're a motivated and compassionate Registered Nurse with a passion for clinical review and oversight, we encourage you to apply for this exciting position. About Our Company and Culture Amerit Consulting is a fast-growing staffing and consulting firm founded in 2002. We specialize in providing consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies and small to mid-sized organizations across the United States. With over 2,000 employees in 47 states, we pride ourselves on delivering exceptional service and creating value by bringing together the right people to achieve results. Our company culture is built on a foundation of respect, inclusivity, and a commitment to excellence. Job Overview Our client, a mutual benefit corporation and health plan provider, is seeking an experienced Sr. Appeals & Grievances Registered Nurse to join their Medi-Cal Member Appeals and Grievances team. As a key member of this team, you will be responsible for clinically reviewing member appeals and grievances resulting from preservice, post-service, or claim denials. This is a 9-month contract position with the possibility of extension or conversion to a full-time role. Key Responsibilities: Perform accurate and timely clinical reviews of member-initiated appeals, utilizing National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and nationally recognized sources such as NCCN and ACOG. Review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy, and medical policy compliance. Provide clinical oversight of all Medi-Cal grievances, working with medical directors and coordinators to identify Potential Quality Issues (PQI), Quality of Service (QOS) cases, and Quality of Care (QOC) cases. Ensure member's clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited. Act independently using sound clinical judgment and demonstrate the ability to work in a fast-paced team environment. Requirements and Qualifications Essential Qualifications: Current California RN license. 2 years of health insurance or related experience. Software skills: MS Office, MS Excel, Email. Knowledge of Medi-Cal benefits and reviews. Demonstrate the ability to act independently using sound clinical judgment. Preferred Qualifications: Excellent communication skills. Experience working in a team environment, preferably in a healthcare setting. Familiarity with medical terminology and clinical guidelines. What We Offer As a valued member of our team, you will enjoy a competitive compensation package, including: Competitive salary. Opportunities for professional growth and development. Flexible work arrangements, including remote work options. Comprehensive benefits package. Why Join Our Team? At Amerit Consulting, we are committed to creating a work environment that is inclusive, supportive, and rewarding. Our team is dedicated to delivering exceptional service and making a positive impact on the lives of our clients and employees. By joining our team, you will have the opportunity to: Work with a dynamic and passionate team. Contribute to the success of our clients and make a meaningful difference in the lives of others. Develop your skills and expertise in a supportive and collaborative environment. Enjoy a flexible and remote work arrangement. How to Apply If you are a motivated and compassionate Registered Nurse with a passion for clinical review and oversight, we encourage you to apply for this exciting opportunity. Please submit your application today, and our team will be in touch with you promptly. Equal Employment Opportunity Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. We value diversity and inclusion in our workplace and encourage all applicants to apply. Apply for this job