Appeals and Grievances Nurse Specialist RN II

• 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
• Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests
• Investigation, and resolution of clinical member complaints (grievances/appeals) utilizing all regulatory requirements
• Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation
• Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE)
• Investigation and preparation of State Fair Hearing cases as assigned
• Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews
• When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps
• Participates inter-rater reliability training and assessments

• Associate's Degree in Nursing
• At least 5 years of experience in Clinical RN
• At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
• 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
• Good working knowledge of regulatory requirements/standards
• Registered Nurse (RN) - Active, current and unrestricted California License

Bachelor's Degree in Nursing

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)