**Duties and Responsibilities:**

+ Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider)
+ Processes appeals and grievances in accordance with internal company policy
+ Enters data into appropriate medical management services
+ Collaborates with other departments to thoroughly investigate appeal and grievances.
+ Prepares for and participates in regulatory site visits.
+ Additional duties as assigned.

**Minimum Qualifications:**

+ RN **Preferred Qualifications:**

+ Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
+ Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual or Medicare Guidelines.
+ Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email an...