Summary:
Under the general direction of the Grievance & Appeals Regulatory Manager, the Grievance & Appeals Regulatory Nurse is responsible for working directly with providers, delegated entities, and internal departments in investigating and resolving cases, and responding to regulatory agencies to ensure compliance with internal Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations. This position coordinates member care in conjunction with the member’s Providers to provide continuous quality care and assist in the development of quality initiatives. The Grievance & Appeals Regulatory Nurse serves as a resource to personnel and providers.

 

Duties:

• Process all incoming DMHC, DHCS and CMS regulatory cases (Consumer Complaints, Independent Medical Reviews, statement of positions, CMS complaints, etc.) and monitoring timeliness of responses for all Plan lines of business.


• Act as a primary contact between and regulatory agencies in resolving Member grievance and appeals by maintaining positive communication and working closely with Compliance and Legal Departments in resolving Members’ complaints, grievances, and appeals.


• File Plan Grievances and Appeals / Claim Dispute / request State Fair Hearing process; distinguishing between an inquiry, a Grievance, an Appeal, a Claim Dispute, and a quality-of-care issue and know how to triage, resolve, or refer incoming calls/correspondence to appropriate personnel.


• Work closely with the Grievance and Appeals Team, with Internal Departments, and DMHC/DHCS/CMS to ensure all Member appeals are investigated, and care is coordinated appropriately.


• Process Plan level appeal and grievance cases as a result of a filed regulatory complaint.


• Review Member appeals and/or complaints and make appropriate determination based on documentation presented by appealing agent with references to federal, state, and local regulations as well as policy and procedures based on line of business in a timely manner.


• Manage all incoming court documents related to State Fair Hearing (SFH) cases, including preparing for scheduled SFH cases, preparation of witness (e.g., Medical Director) and arranging for appearance / telephonic requests of witnesses as well as exhibit gathering.


• Docket hearing notices, contact State / Office of Administrative hearings, establish duties and time frames in connection with each hearing and disseminate information with follow-up as appropriate.


• Support legal department as requested, to include participating in Plan Civil matters.


• Provide testimony on behalf of the company at the administrative hearing and represent the company at hearings (virtual or in-person) when necessary and appropriate.


• Ensure Member appeals are fully investigated, to ensure timely and accurate decisions to either uphold or overturn denial using appropriate criteria hierarchy and work closely with Medical Director for approval.


• Ensure that written correspondence to Providers, Members, and regulatory entities is generated accurately and timely.


• Provide support to the Civil Rights Coordinator with affiliated investigations both at the Plan level and for the Office of Civil Rights.


• Responsible for identifying potential cases that are high risk and using critical thinking to escalate to Manager and make appropriate decisions.


• Participate in LEAN initiatives using A3 thinking and LEAN concepts.


• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

 

 

Education & Requirements 

• Three (3) or more years of experience with 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 required


• Experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar) required


• Experience in either State Fair Hearing (SFH) or Appeals or Grievances referred


• Advanced professional reporting experience within Microsoft Excel preferred


• Experience preparing professional, data driven narrative reports for all staff levels preferred


• Legal processing experience preferred


• High School Diploma or GED required


• Bachelor’s degree in a Health-related field from an accredited institution preferred


• Obtain Center for Medicare and Medicaid Services (CMS) Annual Certification within six (6) months of hire


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


• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN preferred

 

Key Qualifications

• Must have a valid California Driver's License


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


• Knowledge of applicable laws, regulations, Welfare & Institution codes, assembly bills and All Plan Letters that are affiliated with the IEHP’s managed care setting


• Generate written correspondence using appropriate grammar and punctuation


• Microcomputer applications: spreadsheet, database, and word processing required


• Excellent written and verbal communication skills


• Proven ability to:


• Demonstrate critical thinking, good judgment, and strong problem-solving capability


• Prioritize work to ensure adherence to project deadlines


• Effectively escalate issues as identified, following established protocols


• Demonstrate a commitment to incorporate LEAN principles into daily work


• Show strong attention to detail


• Possess a positive attitude and ability to work in a team setting


• Exhibit flexibility in job roles and responsibilities


• Express a strong drive to “do the right thing” and adhere to IEHP Mission, Vision and Values


• Word processing and data entry involving computer keyboard and screens. 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