Grievance & Appeals Nurse Specialist RN
The Judge Group Inc.

Job Info

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Location: Orange, CA
Description: Our client is currently seeking a Grievance & Appeals Nurse Specialist RN

Job Summary

The Grievance and Appeals Nurse Specialist participates in managing the organization's medical appeals and State Hearing reviews for all lines of business; including handling expedited and standard requests. Ensures appeals and State Hearing requests are processed in accordance with regulations, compliance standards and policy and procedures. Investigation and preparation of case narratives and Statements of Position based on clinical information, benefits, applicable regulations related to member or provider dispute of decisions. Clearly articulates the facts and the Client's position regarding dispute to Administrative Law Judge hearing the case. The incumbent is also responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.

Position Responsibilities

• Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
• Presents recommendations based on clinical review, criteria and organizational policies to Client's physician reviewers for final determination.
• Resolves complex and sensitive member issues within established timelines.
• Maintains departmental database and records' integrity by accurately entering case actions to assigned cases.
• Analyzes and reports cases through GARS' subcommittee.
• Participates in departmental meetings, trainings and audits as requested.
• Oversees state hearing cases.
• Assists with the notification process to members or providers on the clinical decision issued.
• Discuss appeal process, medical decisions and hearing rights with members.
• Assists members in coordinating their services with providers and communicate the status and outcome to members.
• Prepares position statements and represents Client at State Hearings.
• Other projects and duties as assigned.

Experience & Education

• RN or LVN license to practice in the State of California required
• 5 years of health care experience required; preferably in a managed care environment in related area of responsibility, (i.e. utilization management, quality management, grievances and appeals).
• Bilingual in English and in one of Client's defined threshold language is preferred.

Knowledge of:

• Medicare and Medi-Cal health care program regulations.
• Clinical review processes including how to analyze and research clinical issues.
• Managed care industry, health care, appeals and grievance processes.

If you are someone you know is interested, please send your resume to bkirking@judge.com or call Brittany Kirking at 720-449-7546.

Contact: bkirking@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

This job has expired.