A&G RN Coordinator

A&G RN Coordinator at MJHS summary:

The A&G RN Coordinator manages clinical appeals, grievances, and quality of care concerns for Elderplan and HomeFirst Medicare and Medicaid managed care plans. This role requires strong knowledge of CMS and DOH regulations, evidence-based clinical guidelines, and effective communication skills. The coordinator supports members and providers by ensuring compliance and delivering high-quality patient-centered service.

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.

The RN Coordinator will investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for  Medicare & Medicaid Services), and DOH (Department of Health) regulations.

• Graduate of accredited nursing program; BSN preferred
• 2 years managed care or hospital based ulilization/case management experience
• 2 years minimum clinical experience
• Licensed nurse in New York State
• Proficiency with Microsoft Word, Excel, Power Point and Outlook is required
• Must have excellent written ad verbal communication skills
• Must be comfortable researching current evidence based practice guidelines and protocols
• Must be able to multi-task and managed multiple projects efficiently, meet deadlines, demonstrate analytical/critical thinking skills, and provide excellent customer services that leads to positive problem resolution

Keywords:

RN Coordinator, clinical appeals, managed care, Medicare, Medicaid, case management, quality of care, nursing, patient advocacy, healthcare compliance