Grievance Appeals Nurse Specialist
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Job Description
Job Summary: 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 client 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.
Position Responsibilities
- Participates in a missiondriven culture of highquality performance with a member focus on customer service consistency dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short and longterm goals/priorities for the department.
- 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.
- 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.
- 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.
- 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 client at state hearings.
- Completes other projects and duties as assigned.
Possesses the Ability To:
- Analyze and complete written summaries on clinical cases.
- Conduct research on standards of practice regulations and policies and procedures that are 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.
- Establish and maintain effective working relationships with leadership and staff.
- Communicate clearly and concisely both orally and in writing.
- Utilize computer and appropriate software (e.g. Microsoft Office: Excel Outlook PowerPoint Word) and jobspecific applications/systems to produce correspondence charts spreadsheets and/or other information applicable to the position assignment.
Experience & Education
- High School diploma required.
- Active Licensed Vocational Nurse (LVN) license to practice in the state of California 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).
Knowledge of:
- Medicare and MediCal health care program regulations.
- Clinical review processes including how to analyze and research clinical issues.
- Managed care and health care industries.
- Appeals and grievance processes.
At Sunshine Enterprise USA LLC we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health dental vision and life insurance
401(k) savings plan
Awards and recognition programs
Benefit eligibility is dependent on employment status.
SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity religion sex national origin age veteran disability or genetic information or any other reason prohibited by law in employment.
Analyze and complete written summaries on clinical cases. Conduct research on standards of practice, regulations and policies and procedures that are 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. Establish and maintain effective working relationships with leadership and staff. Communicate clearly and concisely, both orally and in writing. Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.
Employment Type
Full Time
