RN Manager, A&G Clinical Review

The challenges of affordable healthcare continue tocreate new opportunities. Elderplan and HomeFirst, our Medicare andMedicaid managed care health plans, are outstanding examples of howwe are expanding services in response to our patients' and members'needs. These high-quality healthcare plans are designed to helpkeep people independent and living life on their own terms.Responsible for direct oversight and management of clinical reviewprocesses within Appeals & Grievances Department. Ensuresregulatory compliance and timely processing for the Medicare andMedicaid appeal and grievance processes, quality of care concernsand any other inquires requiring clinical review for medicalnecessity, appropriateness of service or clinical quality. Acts assubject matter expert to internal departments and delegated vendorsto assure all are educated and complaint with