Job Abstract

The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance program for L.A. Care Health Plan members under the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director. This position provides assistance to members with health care access and benefit coordination issues, ensuring that clinical grievances and complex issues are investigated and resolved to the member’s satisfaction consistent with L.A. Care Health Plan and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care Health Plan Lines of Business. 

Works with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.

Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.

Investigates Provider Disputes/PDR and prepares clinical summary for Medical Director determination. 

Work with the external providers and PPGs representatives to obtain relevant medical records and communication documentation.

Investigation and preparation of State Fair Hearing cases as assigned.

Prepare resolved complaint files for Centers for Medicare and Medicaid Services(CMS), external review organization (QIO or IRE).

Work with Utilization Management and PNO to facilitate completion of resolution determination.

Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.

Perform other duties as assigned.

Required:
At least 4 years of clinical nurse and managed care experience.

Required:
Excellent interpersonal and communication skills. 

Good working knowledge of regulatory requirements/standards. 

Computer literacy and adaptability to computer learning. 

Time management and priority setting skills.

Must be organized and a team player, able to work effectively with various internal business units, Plan Partners, participating provider groups, and external agencies.

Required:
License Vocational Nursing (LVN)