Day-to-Day Responsibilities

• Review and process member-generated pre-service and post-service appeals and grievances.
• Conduct comprehensive reviews of medical records and supporting clinical documentation.
• Perform accurate first-level clinical reviews in accordance with company policies and regulatory requirements.
• Apply NCD, LCD, Milliman Care Guidelines, NCCN, ACOG, and other recognized clinical criteria when evaluating cases.
• Assess appeals for medical necessity, benefit coverage, coding accuracy, and medical policy compliance.
• Collaborate with Medical Directors, Coordinators, and leadership teams to discuss and resolve complex cases.
• Prepare clear clinical rationales and final appeal determinations.
• Ensure timely processing of appeals while maintaining quality and regulatory standards.
• Identify and communicate any follow-up actions required to support member access to appropriate care.
• Maintain accurate documentation and compliance throughout the appeals and grievance review process.

Required Skills (Top 3 Non-Negotiables)

1. Managed Care Experience – Minimum 2 years with strong knowledge of MCG, LCD, and NCD guidelines.
2. Acute Care or Sub-Acute Clinical Experience – Minimum 2 years of direct clinical nursing experience.
3. Commercial & Medicare Reviews – Experience with health plan benefits, prior authorizations, pre-service and post-service reviews, medical necessity determinations, and appeals processing.

Preferred Skills

• Knowledge of healthcare regulatory requirements including NCQA, CMS, DMHC, and DHCS.
• Strong medical record review skills and proficiency with Excel, Microsoft Office, PDF tools, Shared Drives, Teams, and SharePoint.
• Ability to work in a fast-paced environment with excellent communication, critical thinking, and clinical assessment skills.
• Experience identifying discrepancies in clinical documentation, medical determinations, and coverage decisions.
• Ability to work independently while collaborating effectively within cross-functional teams.

Education & Certification Requirements

• Associate Degree in Nursing (ADN) required
• Bachelor of Science in Nursing (BSN) preferred
• Active California Registered Nurse (RN) License required

Resume Disqualifiers

• Unexplained employment gaps
• Missing RN license information
• Poorly organized or incomplete resumes

Software Skills

• Microsoft Excel
• Microsoft Office Suite
• PDF Tools
• Shared Drive Systems
• Microsoft Teams
• SharePoint

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 45.00/hr.