Grievance and Appeals Nurse (LVN) 2.8 2.8 out of 5 stars Ontario, CA 91761 • Hybrid work Kinetic Personnel Group is recruiting for a Grievance and Appeals Nurse for a $5 billion/year Public Health Plan in the Ontario California area. This government agency is renowned for the work it does in the community and being a great place to work. The Grievance and Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal departments, and the grievance team to ensure grievance cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations. Coordinate care of Members in conjunction with the Member's PCP and IPA and/ or internal Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance and Appeals Nurse serves as a resource person to company personnel, as well as, external practitioners and Providers. When designated, the Grievance and Appeals Nurse will also be responsible for triaging and assigning grievance and appeals cases to ensure timeliness and regulatory requirements are met. This is a non-hospital, business hours (M-F 8-5 PM) call center position on a hybrid schedule - work from home two days a week, in the office three days a week. Major Functions (Duties and Responsibilities) 1. Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC 2. Understand Member and Provider legal rights to access grievance resolution process within respective Provider Organization, DHCS, DMHC, and CMS 3. Ensure compliance with state and federal guidelines including Centers for Medicare and Medicaid Services requirements 4. Work closely with Grievance & Appeals Team under direction of Grievance & Appeals Nurse Manager and Grievance & Appeals Nurse Supervisor to ensure all Member grievance and appeals issues are investigated and care is coordinated appropriately and in adherence to Grievance & Appeals Policies and Procedures 5. Triage new cases to identify medical urgency and potential need for Organizational Determination and notify Immediate Needs team to ensure timely resolution.

Under triage responsibilities ensure following:

a. Complete Quality Assurance Reviews on all new Grievance & Appeal cases for correct classification, categorization, documentation of dates, source, line of business, requestor and priority. Identify potential additional Grievance or Appeal cases necessary and open as needed b. Audit daily reports to assure all Grievance & Appeal cases are captured and opened within regulatory timeframes. Ensure log of all cases opened and/or reviewed is maintained c. Assign new Grievance & Appeal cases to appropriate team for investigation and resolution 6. Comply with mandated reporting obligations and serve as first line to report allegations of physical and sexual abuse to appropriate authorities 7. Review case coding to ensure accuracy, assist in resolution of Member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in Member's care 8. Responsible for identifying case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within grievances and appeals and referring to appropriate internal Team Members 9. Prepare recommendations to either uphold or deny appeal using appropriate criteria hierarchy and forwards to Medical Director for approval 10. Prepare files for Appeals Committee reviews 11. Serves as subject matter expert for appeals and is resource for clinical and non-clinical Team Members in expediting resolution of outstanding issues. Maintain all appeals documentation according to external agency requirements 12. Grievance & Appeals Nurse shall assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits) and other processes for Members 13. Responsible for serving as resource for internal departments, as well as direct Grievance & Appeals Team Members 14. Grievance Nurse shall notify Grievance & Appeals Management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified Members. Responsible for initial medical review and clinical oversight of all received team cases 15. Responsible clinical oversight of assigned Grievance Team cases, to include final nurse review of all non-quality of are grievance cases and thorough investigation of all quality of care cases to be reviewed by internal Medical Director and designated Nurse Reviewer 16. Responsible for working with Team Members to support protocols and goals of department and vision of organization

Requirements:

Possession of a high school diploma or equivalent. Vocational Nurse (LVN) license issued by the California BRN (active, unrestricted, and unencumbered) Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting. Knowledge of outside agencies and resources such as;

CCS, CMS, DMHC.

Valid California Driver's License Job Types:

Full-time, Temporary Pay:

$29.00 - $32.00 per hour

Benefits:

Dental insurance Health insurance Vision insurance

Experience:

Grievance & Appeals:

2 years (Preferred) Utilization management: 2 years (Required)

License/Certification:

LVN (Preferred)

Work Location:

Hybrid remote in Ontario, CA 91761