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 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.

Responsibilities:
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

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

Must have a valid California Driver's License