- Full Time/Contract
- Case Management
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company To Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Grievance Nurse – LVN
Under the general direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, the Grievance Nurse is responsible for working directly with the IPAs, Hospitals, internal Company 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 Company Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance Nurse serves as a resource person to Company personnel, as well as, external practitioners and Providers.
- Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
- Understand Member and Provider legal rights to access the grievance resolution process, within the respective Provider Organization and Company.
- Implement management of grievance cases ensuring compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements.
- Work closely with the grievance team under the direction of the Grievance Nurse Supervisor with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/Client/CMS to ensure all Member grievance issues are investigated, and care is coordinated appropriately.
- Grievance Nurse is to review case coding, assist in the resolution of Member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the Member’s care.
- Responsible for resolving medical grievances, in conjunction with Company staff, Grievance Management, and Providers, as applicable.
- Responsible for identifying case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within grievances and referring to appropriate Company Team Members.
- Grievance Nurse shall assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for Company Members.
- Responsible for serving as a resource for Company departments, as well as direct Grievance & Appeals Team Members.
- Grievance Nurse shall notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified Company Members. Responsible for initial medical review and clinical oversight of all received team cases.
- Responsible clinical oversight of assigned Grievance team cases, to include; final nurse review of all non-Quality of Care Grievance cases and thorough investigation of all Quality of Care cases to be reviewed by Company Medical Director and designated Nurse Reviewer.
- Ensure all team Grievance cases are processed thoroughly and timely as outlined in Company policy and procedures and per regulatory guidelines.
- Ensure all necessary follow up is tasked for completion by designated MedHOK business partners.
- Generates written correspondence to Providers, Members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation.
- Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.
- Demonstrate a commitment to incorporate LEAN principles into daily work.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company’s policies and procedures relating to HIPAA compliance.
- Any other duties as required to ensure Plan operations are successful.
Possession of a valid LVN license issued by the State of California required. Possession of a valid State of California driver’s license.
|Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting. Experience in an HMO or experience in managed care setting preferred.|
|Knowledge of outside agencies and resources such as; CCS, CMS, DMHC, or DHCS. Microcomputer applications: spreadsheet, database, and word processing. Ability to demonstrate critical thinking, strong problem solving capability, excellent written and verbal communication skills. Strong attention to detail. Ability to prioritize work to ensure adherence to project deadlines. Ability to effectively escalate issues as identified, following established protocols. Positive attitude and ability to work in a team setting.|
HOURS & COMPENSATION
Monday Friday; Days
Full Time, Contract