- Full Time/Contract
- 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 Triage Nurse RN / LVN
Under the general direction of the Grievance & Appeals Nurse Manager and closely aligned with the Grievance Supervisor, the Grievance Triage Nurse is responsible for triaging and assigning Grievance and Appeal cases and working directly with the Grievance team to ensure compliance with Grievance policies and procedures, and agency regulations and standards. The Grievance Triage Nurse serves as a resource person to Company personnel, as well as external practitioners and Providers.
- Maintain working knowledge of regulatory guidelines surrounding Grievances and Appeals per CMS, DHCS, and DMHC.
- Understand Member and Provider legal rights to access the Grievance and Appeals 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.
- Understand Member and Provider legal rights to access the Grievance and Appeals resolution process through Providers, Company, DHCS, DMHC, and CMS.
- Work closely with the Grievance team under the direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, to ensure all Member Grievance and Appeal cases adhere to Grievance policies and procedures.
- Review all systems throughout the day to ensure all cases are captured and assigned appropriately. Systems include: cases entered into electronic case tracking system by Company Member Services and forwarded by other Company Departments, received online, via ground mail, in person, via facsimile and Medicare Complaint Tracking Module (CTM).
- Triage new cases to identify medical urgency and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution.
- Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities.
- Complete Quality Assurance Reviews on all new grievance 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.
- Audit daily reports to assure all Grievance and Appeal cases are captured and opened within regulatory timeframes. Maintain a daily log of all cases opened and/or reviewed by the Grievance Triage Nurse team.
- Assign new grievance and appeal cases to the appropriate Grievance/Appeal team for investigation and resolution.
- Ensure Grievance and Appeal cases are resolved within all Company, as well as all other regulatory agency guidelines. This includes timely and accurate documentation and follow-up by Company personnel and/or any delegated Provider representatives.
- Mentor new Grievance and Appeal Team Members and perform orientation and training in Grievance/Appeal Triage processes.
- Under the direction of the Grievance & Appeals Nurse Manager, and in collaboration with Grievance Supervisor, shall assist with interpreting departmental policies, procedures, regulations, benefits, and processes for Company Members.
- Serve as a resource and liaison between Company Medical Services Departments, Provider Services, Member Services, and the Grievance team for continuity of care issues and referral of Members to appropriate Company Programs, and Quality Management for follow up and tracking as indicated.
- Ensure grievance/appeal cases are documented and coded properly.
- Assist in writing and updating grievance policies and procedures as needed. Ensure procedures comply with DMHC, DHCS, CMS, and all other Plan regulators. Maintain NCQA compliance.
- Demonstrate a commitment to incorporate LEAN principles into daily work.
- Any other duties as required to ensure Company operations are successful.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company’s policies and procedures relating to HIPAA compliance.
|Education/License:||Possession of a valid LVN or RN license issued by the State of California. Possession of a valid State of California driver’s license.|
|Experience:||Two (2) or more years of individual or combined experience in Grievance systems, Appeals, Case Management, Utilization Management, and/or related experience in a health care delivery setting. Experience in an HMO or Managed Care setting preferred.|
|Knowledge/Skills Required:||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. Bilingual (written and verbal) strongly preferred.|
HOURS & COMPENSATION
Monday Friday; Days
RN $40 / LVN $25
Full Time, Contract