Remote Appeals & Grievances Nurse Specialist RN – California

Job Overview

  • Clinical License RN
  • State(s) CA
Job Description
Our Client, Provides health insurance for low-income individuals, is seeking an Appeals & Grievances Nurse Specialist RN.

Location: Los Angeles, CA (Remote)
Position Type: Contract

Job summary:
• The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member’s with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member’s satisfaction in a manner consistent with Clients of Medicare and Medicaid Services (CMS) and regulatory guidelines.
• Benefit coordination may involve coordinating multiple Client products, Fee for services (FFS )Medi-Cal/Medicare, or commercial insurance.

• Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.
• Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements.
• Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA).
• Identification of Expedited Cases and resolution within 72 hours.
• Works with the external providers and Participating Physician Group’s (PPG) representatives to obtain relevant medical records and communication documentation.
• Investigation and preparation of State Fair Hearing cases as assigned.
• Prepares resolved complaint files for CMS external review organization – Quality Improvement Organization (QIO) or Independent Review Entity (IRE).
• Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews.
• Prepares authorizations, after approval by the Medical Director.
• Perform other duties as assigned.

Education Required:
• Associate’s Degree in Nursing

Education Preferred:
• Bachelor’s Degree in Nursing

Experience Required:
• At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/ Medicaid in a managed care/ health plan environment.
• Good working knowledge of regulatory requirements/standards.

Skills Required:
• Excellent interpersonal and communication skills.
• Computer literacy and adaptability to computer learning.
• Time management and priority setting skills.
• Must be organized and a team player
• Able to work effectively with various internal departments/service areas, Client partners, participating provider groups, and other external agencies.

Licenses/Certifications Required:
• Registered Nurse (RN) – Active, current and unrestricted California License

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