Location: Telecommute out of Rancho Cucamonga, California

Schedule: Monday through Friday 8a to 5p

Pay: $30/hour

Requirements: LVN license, 2 years CM or UM experience

Job Type: Temporary

Quick Summary:

The Grievance & Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal departments, and the grievance team to ensure grievance and appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA. Coordinate care of Members in conjunction with the Member’s PCP and IPA and/ or Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance & Appeals Nurse serves as a resource person to personnel, as well as external practitioners and Providers. When designated, the Grievance and Appeals Nurse will also be responsible for triaging and assigning grievance and appeals cases to ensure timeliness and regulatory requirements are met.

Responsibilities:

1. Maintain working knowledge of regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA.


2. Understand Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS.


3. Implement management of grievance and appeals cases ensuring compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements.


4. Work closely with the Grievance and Appeals Team under the direction of the Grievance Nurse Leadership with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS to ensure all Member grievance issues are investigated, and care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures.


5. Review case coding to ensure it is accurate, assist in the resolution of Member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the Member’s care.


6. Resolve medical grievances, in conjunction with staff, Grievance Management, and Providers, as applicable.


7. Identify case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within Grievances and Appeals and referring to appropriate Team Members


8. Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for Members.


9. Serve as a resource for departments, as well as direct Grievance & Appeals Team Members.


10. Notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified Members. Responsible for initial medical review and clinical oversight of all received team cases.

Education & Requirements 

• Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting


• Experience in an HMO or experience in managed care setting preferred


• High school diploma or GED required


• Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

• Must have a valid California Driver's License


• Knowledge of outside agencies and resources such as; CCS, CMS, DMHC, or DHCS


• Microcomputer applications: spreadsheet, database, and word processing


• Excellent written and verbal communication skills


• Ability to demonstrate critical thinking and strong problem-solving capability


• Strong attention to detail


• Ability to prioritize work to ensure adherence to project deadlines


• Ability to effectively escalate issues as identified, following established protocols


• Positive attitude and ability to work in a team setting


• Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire


• While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell


• The employee must occasionally lift or move up to 25 pounds


• Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus