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Grievance & Appeals Nurse Specialist (Registered Nurse Required)
Job Description: Grievance & Appeals Nurse Specialist (Registered Nurse Required)
The Grievance and Appeals Nurse Specialist participates in managing the organization's medical appeals and State Hearing reviews for all lines of business; including handling expedited and standard requests. Ensures appeals and State Hearing requests are processed in accordance with regulations, compliance standards and policy and procedures. Investigation and preparation of case narratives and Statements of Position based on clinical information, benefits, applicable regulations related to member or provider dispute of decisions. Clearly articulates the facts and CalOptima's position regarding dispute to Administrative Law Judge hearing the case. The incumbent is also responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.
• Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
• Presents recommendations based on clinical review, criteria, and organizational policies to CalOptima's physician reviewers for final determination.
• Resolves complex and sensitive member issues within established timelines.
• Maintains departmental database and records' integrity by accurately entering case actions to assigned cases.
• Analyzes and reports cases through GARS' subcommittee.
• Participates in departmental meetings, trainings and audits as requested.
• Oversees state hearing cases.
• Assists with the notification process to members or providers on the clinical decision issued.
• Discuss appeal process, medical decisions, and hearing rights with members.
• Assists members in coordinating their services with providers and communicate the status and outcome to members.
• Assigns position statements and represents CalOptima at State Hearings.
• Other projects and duties as assigned.
• Communicates clearly and concisely, both verbally and in writing.
• Analyze and complete written summaries on clinical cases.
• Conduct research on standards of practice, regulations and policy and procedures relevant to review cases.
• Communicate issues clearly and timely to members, providers, involved departments or health networks.
• Organize and manage activities related to processing cases within the department.
• Utilize computer and appropriate software (e.g. Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• High School diploma required.
• Current State of California required; RN license to practice in the State of California strongly required.
• 5 years of health care experience required; preferably in a managed care environment in related area of responsibility, (i.e. utilization management, quality management, grievances, and appeals).
• Bilingual in English and in one of CalOptima's defined threshold language is preferred.
• Medicare and Medi-Cal health care program regulations.
• Clinical review processes including how to analyze and research clinical issues.
• Managed care industry, health care, appeals and grievance processes.
Grade N: $71,760 - $114,712
Job Location: Orange, California, United States
Position Type: Full-Time/Regular
To apply, visit https://apptrkr.com/2108272
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