Grievance & Appeals Nurse Specialist

Our client, a well-respected California Healthcare Network, is seeking a highly motivated and experienced Grievance & Appeals Nurse Specialist to join our team.

The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.

The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures.

The incumbent will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions.

The incumbent will clearly articulate the facts and the organization’s position regarding disputes to the Administrative Law Judge hearing the case.

The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.

Duties & Responsibilities :

80% - Program Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

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 physician reviewers for final determination.

Resolve complex and sensitive member issues within established timelines. Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.

Analyzes and reports cases through GARS’ subcommittee. Oversees state hearing cases. Discusses appeal process, medical decisions and hearing rights with members.

Assists members in coordinating their services with providers and communicates the status and outcome to members. Assigns position statements and represents the organization at state hearings.

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• 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 Health’s physician reviewers for final determination.
• Resolves complex and sensitive member issues within established timelines.
• Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
• Analyzes and reports cases through GARS’ subcommittee.
• Oversees state hearing cases.
• Discusses appeal process, medical decisions and hearing rights with members.
• Assists members in coordinating their services with providers and communicates the status and outcome to members.
• Assigns position statements and represents CalOptima Health at state hearings.
• 15% - Administrative Support Participates in departmental meetings, trainings and audits as requested. Assists with the notification process to members or providers on the clinical decision issued.
• Participates in departmental meetings, trainings and audits as requested.
• Assists with the notification process to members or providers on the clinical decision issued.
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications :

• High School diploma required.
• 5 years of health care / managed care experience required. Preferably in the following related areas of responsibility : Grievances and Appeals, Utilization Management and / or Quality Management.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications :

• Active Registered Nurse (RN) license to practice in the state of California.
• Bilingual in English and in one of the defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Required Licensure / Certifications :

Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.

Knowledge & Abilities :

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees / coalitions.
• 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.

Physical Requirements (With or Without Accommodations) :

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication / conversation / responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and / or equipment 10 to 25 pounds

The Midtown Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.