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Grievance Nurse, LVN

Location : Ontario, CA
Job Type : Temp/Contract
Reference Code : 7546
Required Years of Experience : 2 years
Required Education : High School Diploma or GED
Job Industry : Healthcare - Health Services

Job Description :



Position Summary/Position


Under the general direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, the Grievance Nurse, LVN is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the grievance team to ensure grievance 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. Coordinate care of Members in conjunction with the Member’s PCP and IPA and/ or IEHP Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance Nurse, LVN serves as a resource person to IEHP personnel, as well as external practitioners and Providers. When designated, the Grievance and Appeals Nurse, LVN will also be responsible for triaging and assigning grievance and appeals cases to ensure timeliness and regulatory requirements are met.

Major Functions (Duties and Responsibilities)


1. Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC. 
2. Understand Member and Provider legal rights to access the grievance 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 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. Grievance Nurse is to 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. Responsible for resolving medical grievances, in conjunction with staff, Grievance Management, and Providers, as applicable.
7.  Responsible for identifying 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. Grievance Nurse shall assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for Members.
9. Responsible for serving as a resource for departments, as well as direct Grievance & Appeals Team Members.
10. Grievance Nurse shall 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.
11. Responsible clinical oversight of assigned Grievance and Appeals team cases, to include final nurse review of all Non-Quality of Care Grievance and Appeals cases and thorough investigation of all Quality-of-Care cases to be reviewed by the Medical Director and designated Nurse Reviewer.
12. Ensure all team Grievance and Appeals cases are processed thoroughly and timely as outlined in the policy and procedures and per regulatory guidelines.
13. Ensure all necessary follow up is tasked for completion by designated MedHOK business partners.
14. Generates written correspondence to Providers, Members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation. 
15. Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.


Required Qualifications :



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


Preferred Experience

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


High school diploma or GED required.


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


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.


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.


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