Customer Solution Center Appeals and Grievances Nurse Specialist RN II
Updated: March 12
Los Angeles
Expired
0
0mi
Job Abstract
The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L. A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L. A. Care ... more details
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS )Medi-Cal/Medicare, or commercial insurance.
Duties
Conducts intake/triage and appropriate classification of Clinical A&G, 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/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identification of Expedited Cases and resolution within 72 hours.
Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).
Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
Perform other duties as assigned.
Duties Continued
Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience
Required: At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/ Medicaid in a managed care/ health plan environment.
Good working knowledge of regulatory requirements/standards.
Skills
Required: Excellent interpersonal and communication skills.
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 departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.
Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
Job Abstracts is an independent Job Search Engine. Job Abstracts is not an agent or representative and is not endorsed, sponsored or affiliated with any employer. Job Abstracts uses proprietary technology to keep the availability and accuracy of its job listings and their details. All trademarks, service marks, logos, domain names, and job descriptions are the property of their respective holder. Job Abstracts does not have its members apply for a job on the jobabstracts.com website. Additionally, Job Abstracts may provide a list of third-party job listings that may not be affiliated with any employer. Please make sure you understand and agree to the website's Terms & Conditions and Privacy Policies you are applying on as they may differ from ours and are not in our control.
Any time you conduct a search, the system shows you job matches, ranked by their Relevance Score (RS).
The score is calculated by a proprietary algorithm that uses Intelligent Machine Learning.
The Relevance Score tells you how well the job opportunity matches your search term or terms.
When not logged in, the system is limited to one search term. Scores for single term matches are usually lower.
When you register, log in, and set up multiple terms prioritized by importance, the jobs found for you will receive a much higher Relevance Score.