Grievance and Appeals Nurse Specialist

Job Description

Position Responsibilities

• Prepares clinical reviews and provides monitoring of cases involving medical decisions and quality or care or service, and ensures all cases are completed in accordance with State and Federal regulatory requirements for timelines.

• Meets timeframes for performance with balancing the need to produce high quality work and resolving complex and sensitive member issues.

• Ensures integrity of departmental database and recording maintenance by thorough, timely and accurate entry of cases assigned. 

• Assists with analyzing and reporting of cases through the GARS Subcommittee.

• Participates in departmental meetings, trainings and audits as requested.

• Oversight of State Hearing cases.

• Assists with the intake/notification process of cases in the department. 

• Prepares position statements and represents company at State Fair Hearings.

• Other projects and duties as assigned.

Possess the Ability to:

• Analyze and complete written summaries on clinical cases.

• Conduct research on standards of practice, regulations and policy and procedures relevant to review cases.

• Provide oversight and training to staff on GARS procedures and requirements.

• Communicate issues clearly and timely to members, providers, involved departments or health networks.

• Organize and manage activities related to processing cases timely and accurately within the department and regulatory standards.

Qualifications

Required Experience & Education

• Current RN or LVN License to practice in the State of California.

• 5 years of health care experience, preferably in a managed care environment in related area of responsibility, i.e. utilization management, quality management, grievances and appeals.

• Strong interpersonal, verbal and written communication skills.

• Strong problem solving skills, implementing initiatives or projects, and collaborating with other professional and non-clinical staff.

Knowledge of:

• Medicare, Medi-Cal and Healthy Families health care program regulations.

• Clinical review processes including how to analyze and research clinical issues.

• Computer applications including MS Office suite.

• Business communication skills.

• The managed care industry, health care processes.

• Appeals and grievance processes.

• Managed care organizational operations.

Additional Information

If you feel that you have the skills we require, please respond to this posting with your contact information and your resume in a Word document.  We look forward to hearing from you today! 

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