Lead Customer Solution Center Appeals and Grievances RN Job at L.A. Care Health Plan (Los Angeles)

Job Description

The Lead Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all lines of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines. Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.

Job Responsibility

Review and process complex and/or escalated clinical A&G cases
Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity
Prepares and reviews A&G files for submission to providers and internal departments
Work with other departments to ensure all aspects of a case are appropriately managed
Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met
Work closely with the leadership team to create and/or modify Desk Level Procedures and recommend enhancements to process and procedures
Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels
Recommend and implement resolutions, new processes, and/or process improvement
Provide accurate and timely written statistical reports that include historical and/or current data to aid in projecting or evaluating compliance status
Identify and analyze trends in appeals and grievances to find the root cause of denials
Check, verify and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance
Maintain documentation of all communications in the A&G system to ensure thorough tracking of case status
Lead the work of assigned staff
regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management
Work closely with management to review performance and quality standards on an ongoing basis
Act as a back-up to the Supervisor in leading meetings and handling escalations as required
Perform other duties as assigned

Requirements

Associate's Degree in Nursing for Registered Nurses
At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting
At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
At least 1 year of leading a process, program, or staff experience
Extensive knowledge of healthcare regulations and managed care guidelines
Demonstrated ability to provide recommendations towards resolution
Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity
Ability to communication, conflict resolution, and motivational skills
Ability to work independently and closely with a team in a collaborative and interactive environment
Ability to adjust to changing circumstances within the team
Good verbal and written communication skills
Registered Nurse (RN) - Active, current and unrestricted California License

Nice to have

Bachelor's Degree in Nursing for Registered Nurses
Clinical acute experience
Strong project management skills with the ability to manage multiple training initiatives simultaneously

What we offer

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

L.A. Care Health Plan - All Job Offers

Select Country

Lead Customer Solution Center Appeals and Grievances RN

Job Description

Job Responsibility

Requirements

Nice to have

What we offer

Looking for more opportunities?

Lead Customer Solution Center Appeals and Grievances RN

Early Morning Warehouse Co-worker

Shift Leader

Mobile Associate

Shift Leader

Shift Leader

Store Manager

Programme Assistant for Policy and Public Affairs

Technician Kitchen & Laundry

Our AI answers in your language