Our client is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. They are the nation’s largest publicly operated health plan. Serving more than 2 million members in six health plans, our client ensures members get the right care at the right place at the right time. SUMMARY: The Grievance and Appeals Nurse Specialist provides direct assistance to member's clinical health care concerns and are investigated and resolved to the member's satisfaction. This may be through the G & A Grievance and/or Appeal Process, as well State Fair Hearings and other Regulatory Agency requests RESPONSIBILITIES:· Conducts intake/triage and appropriate classification of Clinical Appeals, Grievances, 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/PDR (grievances/appeals) utilizing regulatory and internal guidelines and SLA· Investigation and preparation of State Fair Hearing cases as assigned.· Prepare resolved complaint files for CMS external review organization (QIO or IRE).· Conduct reviews and present to physicians, provider disputes which would be based on medical necessity reviews.· Identification of cases requiring further review internally based on meeting initial criteria.· Makes recommendations for corrective action, benefit coordination issues, database modifications, to the manager. QUALIFICATIONS AND REQUIREMENTS: · Associate, Diploma or Bachelor's Degree in Nursing required or 2-3 years of college - technical school or business school· Bilingual preferred· Registered Nurse with an active, current, unrestricted California License required· Clinical Nursing 2 years; Managed Care -1 year; Medicare -1 year required· Excellent interpersonal and communication skills required· Good working knowledge of regulatory requirements/standards required· Computer literacy and adaptability to computer learning required· Time management and priority setting skills required· Clinical Nursing 3 years; Managed Care for 2 years preferred
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