Description:

The Grievance & Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal client 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 client 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 client 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.

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 client 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 client departments/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 client 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 client Team Members.

Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for client 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 client requirements. Serve as a resource for client 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 client 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 client 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 client 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 client business needs are successful.

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 CA Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

Must have a valid CA 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 the client

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

Notes:

Hybrid