Description
Job Description:- The Grievance & Appeals Nurse Specialist provides direct assistance to members 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 regulatory guidelines.
- Benefit coordination may involve coordinating multiple products, FFS Medi-Cal/Medicare, or commercial insurance.
- The successful candidate must be organized and a team player with excellent communication skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups, and other external agencies.
- Conducts intake/triage and appropriate classification of Clinical Appeals, Grievances, 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/PDR (grievances/appeals) utilizing regulatory and internal guidelines and SLA
- Identification of Expedited Cases and resolution within 72 hours
- 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 CMS external review organization (QIO or IRE).
- Conduct reviews and present to physicians, provider disputes which would be based on medical necessity reviews.
- Prepare authorizations, after approval by the Medical Director
- Identification of cases requiring further review internally based on meeting initial criteria.
- Makes recommendations for corrective action, benefit coordination issues, database modifications, to the manager.
- Workload is based on issues, cases, grievances, appeals and SFHs, that are forwarded from the Call Center and external entities: the Ombudsman, Plan Partners, and member advocates.
- Perform other duties as assigned.
Skills/Qualifications:
- Associate, Diploma or Bachelor's Degree in Nursing required
- BSN or BA in Health Care or a related field a plus preferred
- Bilingual preferred
- Registered Nurse with an active, current, unrestricted California License required
- Clinical Nursing 2 years; Managed Care -1 year; Medicare -1 year required
- Excellent interpersonal and communication skills required
- Good working knowledge of regulatory requirements/standards required
- Computer literacy and adaptability to computer learning required
- Time management and priority setting skills required
- Clinical Nursing 3 years; Managed Care for 2 years preferred