Grievance and Appeals Nurse Specialist

Overview

Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance andappeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of casesto ensure members receive high quality healthcare services. Working closely with PHC MedicalDirectors, oversees assessments for medically necessary determinations, quality of careconcerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadershipto Grievance & Appeals Case Analysts to ensure clinical solution followed on casework.Ensures casework complies with DHCS guidelines, NCQA standards, and PHC best practices.Works independently, prioritizes case deliverables, remains customer-focused and stays currenton changes in the healthcare system that may trigger member dissatisfaction. This position iseligible for teleworking.

Responsibilities

• Assesses all cases to determine if members have any emergent or immediatemedical needs. Identifies potential quality of care, fraud, waste, and abuse issues.Takes appropriate actions.
• Executes independent clinical judgement in assessing members concern, care andtreatment. Evaluates and solves for any deviations in the standard of care,regulations, policy and procedures relevant to assigned cases.
• Conducts comprehensive clinical assessments as they relate to a member’sphysical, psychosocial, environmental, safety, developmental, cultural and linguisticneeds. Takes appropriate actions.
• In coordination with the Grievance & Appeal Case Analyst, may contact members asit directly relates to their immediate clinical concerns. May refer to Care Coordinationfor continued/ongoing case management.
• Assesses and formally classifies disputed benefits according to NCQA pre-serviceand post-service classifications.
• Provides guidance to determine if/which medical records are needed to thoroughlyevaluate the substance of on grievance and appeal cases.
• Evaluates all received medical records and writes clinical summary of observationsin preparation of MD Director’s review. Medical records average 30-500 pages percase.
• Works closely with Grievance & Appeal Case Analyst, ensuring clinical content ofresolution letters reflect clinical accuracy and medical terms are written in laymanlanguage
• Responsible for end-to-end investigation of exempt grievances. Works closely withPHC Medical Directors to identify and address concerns related to quality of care,HIPAA violations, fraud, waste, or abuse activity.
• Documents all casework activity thoroughly, accurately, timely, and ethically.
• Manages assigned cases so they are completed within DHCS timeframes, accordingto G&A Desktop procedures, and/or as directed by management.
• Serves as a clinical resource to the Grievance & Appeals team
• Identifies systematic or recurring issues that create barriers to high quality healthcareand reports them to leadership.
• Can work in a team environment
• Effective communicator in all modes of communication (e.g., written, verbal)
• May serve as a backup to absent Grievance & Appeals Nurse Specialists
• Attends meetings as needed including but not limited to Clinical Case Forum meetings,Department Meetings, and Division Meetings
• Maintains a Registered Nurse licensure in good standing
• Other duties as assigned.

Qualifications

Education and Experience

Bachelor’s degree in Nursing, 3-5 years’ experience to include at least one(1) year of case management experience and one (1) year in an acutecare setting; or equivalent combination of education and experience. CCMdesired. Knowledge of PHC Grievance & Appeals processes. Generalknowledge of managed care with emphasis in UM or CM preferred.

Special Skills, Licenses and Certifications

Current California Registered Nurse license. Critical thinker. Organized.Thorough knowledge of utilization and case management programs andrelated criteria and protocols. Experience in managed care businesspractices and ability to access data information using computer systems.Ability to work within an interdisciplinary structure and functionindependently in a fast-paced environment while managing multiplepriorities and meeting deadlines. Strong organizational skills required.Effective telephone and computer data entry skills required. ValidCalifornia driver’s license and proof of current automobile insurancecompliant with PHC policy are required to operate a vehicle and travel forcompany business.

Performance Based Competencies

Excellent written and verbal communication skills with ability to read andinterpret benefit contract specifications are required. Ability to applyclinical judgment to complex medical situations and make quick decisionsin a fast-paced environment. Works well under pressure and maintains aprofessional composure when interacting with all stakeholders, includingmembers.

Work Environment And Physical Demands

Daily use of telephone and computer for most of the day. Standardcubicle workstation or telecommute eligible. When required, ability tomove, carry or lift objects weighing up to 25 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be

HIRING RANGE:

 $103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.