What are the responsibilities and job description for the Grievance & Appeals Nurse Specialist position at CareNational?
Grievance & Appeals Nurse Specialist
Orange, CA
Highlights Of The Role
Orange, CA
Highlights Of The Role
- Competitive Pay: Up to $67 per hour
- Work Environment: Full Office
- Mission-Driven Culture:
- Department: Grievance & Appeals
- Work Arrangement: Full Office
- Work Schedule: Monday to Friday (8:00 am to 5:00 pm)
- 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 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.
- 5% - Completes other projects and duties as assigned.
- 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.
- Active Registered Nurse (RN) license to practice in the state of California.
- Bilingual in English and in one of CalOptima Health's 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.
- Health, Dental & Vision Insurance
- Weekly Pay
- Referral Bonus
- 401(k) Matching
Salary : $67
