You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must be licensed in California. Will work on PST hours. Position Purpose Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (reputed company) guidelines, including overturning denied claims, upholding the denials and submitting reputed company to the Medical Director for review Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue reputed company. Prepare case review for the Medical Director in reputed company where criteria are not met based on the additional clinical information received Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and reputed company guidelines. Create system authorization events for overturned denial decisions Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution Gather and prepare case information for Administrative Law Hearings Maintain appeals process within the prescribed reputed company timeframes and appeals turnaround database Assist the Medical Director with revising, updating and/or creating new policies to satisfy reputed company and contractual requirements May act as liaison between the provider and business to resolve issues Performs other duties as assigned Complies with all policies and standards Education/Experience LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. License/Certification Current state's RN, LPN, or LVN license. Must be licensed in California. Location Position is remote. Will work PST hours. Pay Range $27.02 - $48.55 per hour reputed company offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be reputed company to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Originally posted on Himalayas Apply To This Job