IEHP

Nonprofit public health plan for the Inland Empire

Grievance & Appeals Nurse

Medical, Clinical & VeterinaryPosted on Nov 9

Full-timeCalifornia, USA

About the Job

Requirements

Two or more years of case management, utilization management in a managed care setting, or related experience in a health care delivery setting.
A high school diploma or GED is required.
An active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians is required.
A valid California driver's license is required.
Working knowledge of member and provider legal rights to access the grievance and appeals resolution process through the respective Provider Organization, DHCS, DMHC, CMS, and IEHP is required.
Working knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS is required.
Working knowledge of regulatory guidelines surrounding grievances and appeals per CMS, DHCS, DMHC, and NCQA is required.
Proficiency with spreadsheet, database, and word-processing applications is required.
Ability to demonstrate critical thinking and problem-solving capability is required.
Ability to incorporate LEAN principles into daily work is required.
Strong attention to detail is required.
Ability to prioritize work to meet project deadlines is required.
Ability to escalate issues effectively in accordance with established protocols is required.
Ability to work in a team setting is required.

Responsibilities

Implement management of grievance and appeal cases in compliance with state and federal guidelines, including CMS requirements.
Ensure team grievance and appeal cases are processed thoroughly and timely in accordance with IEHP policies, procedures, and regulatory guidelines.
Ensure member grievance issues are investigated, and care is coordinated appropriately in accordance with grievance and appeals policies and procedures.
Work with the Grievance and Appeals Team, under the direction of Grievance Nurse Leadership, and with Member Services, Provider Services, Compliance, and Medical Services departments, as well as DMHC, DHS, and CMS, to review grievance issues.
Review case coding for accuracy, assist in resolving member medical issues, and coordinate care with practitioners, providers, and entities or agencies involved in member care.
Resolve medical grievances with IEHP staff, Grievance Management, and providers, as applicable.
Identify case issues, assist in developing quality initiatives, refer cases to outside agencies, identify other system issues within Grievances and Appeals, and refer issues to appropriate IEHP team members.
Assist with interpreting departmental policies, procedures, regulations, benefits, including evolving benefits, and other processes for IEHP members.
Serve as a grievance and appeals subject matter expert and resource for clinical and non-clinical team members to expedite resolution of outstanding issues.
Maintain grievance and appeals documentation according to external agency requirements and serve as a resource for IEHP departments and Grievance and Appeals Team Members.
Notify Grievance and Appeals management of trends related to contracted practitioners and providers to support continuity of care for identified IEHP members.
Provide clinical oversight of assigned grievance and appeals team cases, including final nurse review of all non-Quality-of-Care grievance and appeal cases and thorough investigation of Quality-of-Care cases for review by the IEHP Medical Director and designated Nurse Reviewer.
Perform initial medical review and clinical oversight of all received team cases.
Ensure necessary follow-up is assigned for completion by designated MedHOK business partners.
Generate written correspondence to providers, members, and regulatory entities using approved templates and appropriate grammar and punctuation.
Work with team members to support department protocols and goals and the organization's vision.
Triage new cases to identify medical urgency and potential need for Organizational Determination, and notify the Immediate Needs team to ensure timely resolution.
Complete quality assurance reviews on new grievance and appeal cases for correct classification, categorization, documentation of dates, source, line of business, requestor, and priority; identify and open any additional necessary grievance or appeal cases.
Audit daily reports to ensure all grievance and appeal cases are captured and opened within regulatory timeframes, and maintain the log of cases opened or reviewed.
When designated, assign new grievance and appeal cases to the appropriate team for investigation and resolution.
Comply with mandated reporting obligations and report allegations of physical and sexual abuse to appropriate authorities as the first line.
Prepare recommendations to uphold or deny appeals using appropriate hierarchy criteria and forward them to the Medical Director for approval.
Prepare files for Grievance and Appeals Committee reviews.
Perform other duties as required to support health plan operations and department business needs.

Desired Qualifications

Experience in an HMO or managed care setting is preferred.
An associate’s degree from an accredited institution is preferred.

Overview

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

The Grievance & Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the grievance team to ensure grievance and appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA. Coordinate care of Members in conjunction with the Member’s PCP and IPA and/ or IEHP Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance & Appeals Nurse serves as a resource person to IEHP personnel, as well as external practitioners and Providers. When designated, the Grievance and Appeals Nurse will also be responsible for triaging and assigning grievance and appeals cases to ensure timeliness and regulatory requirements are met.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Key Responsibilities

Implement management of grievance and appeals cases ensuring compliance with state and federal guidelines, including Centers for Medicare, and Medicaid Services requirements

Ensure all team grievance and appeals cases are processed thoroughly and timely as outlined in IEHP policy and procedures and regulatory guidelines

Ensure all member grievance issues are investigated and care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures

Work closely with the Grievance and Appeals Team under the direction of the Grievance Nurse Leadership with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS in reviewing grievance issues

Review case coding to ensure it is accurate, assist in the resolution of member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the member’s care

Resolve medical grievances, in conjunction with IEHP staff, Grievance Management, and Providers, as applicable

Identify case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within Grievances and Appeals and referring to appropriate IEHP Team Members

Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for IEHP members

Serve as a subject matter expert for grievance and appeals and is a resource for clinical and non-clinical Team Members in expediting the resolution of outstanding issues

Maintain all grievance and appeals documentation according to external agency requirements. Serve as a resource for IEHP departments, as well as direct Grievance & Appeals Team Members

Notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified IEHP members

Ensure clinical oversight of assigned Grievance and Appeals team cases, to include final nurse review of all Non-Quality of Care grievance and appeals cases and thorough investigation of all Quality-of-Care cases to be reviewed by IEHP Medical Director and designated Nurse Reviewer

Responsible for initial medical review and clinical oversight of all received team cases

Ensure all necessary follow up is tasked for completion by designated MedHOK business partners

Generate written correspondence to Providers, members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation

Work with Team Members to support the protocols and goals of the department and the vision of the organization

Triage new cases to identify medical urgency and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution

Complete Quality Assurance Reviews on all new grievance and appeal cases for correct classification, categorization, documentation of dates, source, line of business, requestor, and priority. Identify potential additional grievance or appeal cases necessary and open as needed

Audit daily reports to assure all grievance and appeal cases are captured and opened within regulatory timeframes. Ensure the log of all cases are opened and/or reviewed is maintained

When designated, assign new grievance and appeal cases to the appropriate team for investigation and resolution

Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities

Prepare recommendations to either uphold or deny appeal using appropriate hierarchy criteria and forward to Medical Director for approval

Prepare files for Grievance and Appeals Committee reviews

Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Requirements

Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting
- Experience in an HMO or experience in managed care setting preferred
High school diploma or GED required
- Associate’s degree from an accredited institution preferred
Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

Must have a valid California Driver's License
Working knowledge and understanding of:
- Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS and IEHP
- Outside agencies and resources such as CCS, CMS, DMHC, or DHCS
- Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA
Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills
Proven ability to:
- Demonstrate critical thinking and strong problem-solving capability
- Demonstrate a commitment to incorporate LEAN principles into daily work
- Possess strong attention to detail
- Prioritize work to ensure adherence to project deadlines
- Effectively escalate issues as identified, following established protocols
- Maintain a positive attitude and ability to work in a team setting

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)

Automobile travel within the Inland Empire

Pay Range

USD $63,897.60 - USD $83,075.20 /Yr.

Compensation: 63897.6 to N/A (USD)

About the Company

IEHP

Nonprofit public health plan for the Inland Empire

IEHP is a nonprofit public health plan that connects residents of California's Riverside and San Bernardino counties with health coverage and care. It administers Medi-Cal coverage for eligible low-income residents, IEHP DualChoice for people with both Medicare and Medi-Cal, and IEHP Covered plans through Covered California. Members receive care through a network of doctors and other providers, with dedicated care teams for those who need extra support. Its community wellness centers run free fitness classes and health workshops, and it connects residents with food and housing resources. IEHP began operating in 1996 and is headquartered in Rancho Cucamonga, California.

Company size: 1,001-5,000
Company stage: Not listed
Total funding: Not listed
Headquarters: Rancho Cucamonga, CA
Founded: 1996

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