Job Overview
This position functions as a member of the Medical Management team and is primarily responsible for reviewing Appeals & Grievances (A&G) cases, reconciling and maintaining tracking databases, and supporting case review activities for Oversight Audits. The role ensures data accuracy, supports audit readiness, and contributes to compliance with regulatory requirements.
ESSENTIAL DUTIES & RESPONSIBILITIES:
- Assists in maintaining standards that are in conformance with federal and state regulations and requirements.
- Gather, review and monitor regular clinical reports from Health Net.
- Perform (or assist with) annual oversight audits of HN clinical functions.
- Assist with preparation for external audits (DHCS, DMHC, NCQA) by gathering and reviewing required documents for clinical functions.
- Prepare/assist with audit summary reports and the implementation of any required corrective action plans.
- Participate as requested in HEDIS® Projects, the DHCS required Quality Improvement Projects, and other QI or UM activities, studies, reviews and surveys.
- Assist in the preparation of required CalViva clinical reports.
MINIMUM QUALIFICATIONS:
Education:
Completion of an accredited nursing program
Licenses:
- Current California nursing license (R.N. OR L.V.N.)
- QI program certification a plus
- Current driver’s license
Experience:
- Minimum of two years’ experience in healthcare environment.
- Health Care Quality Improvement, data analysis, and/or auditing experience.
Knowledge, Skills & Abilities:
- Ability to effectively develop, analyze, interpret, and communicate healthcare data reports and processes.
- Strong analytical and problem-solving skills.
- Must be at least proficient in Microsoft Office: Word, Excel, PowerPoint, Access and Outlook.
- Possess the ability to prioritize projects appropriately and multi-task.
- Ability to take initiative and work independently.
- Effective organizational and communication skills.
- Team player who can establish and maintain effective working relationships at all organization levels.
- Exercise a high degree of maturity, integrity, loyalty, initiative, creativity and sound judgment.
Physical Requirements:
- Constant and close visual work at desk or computer.
- Extensive typing
- Constant sitting and working at desk.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent walking and standing.
- Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lb.
- Must have reliable transportation, may be required to travel between Kings, Madera and Fresno counties as well as between offices for meetings
Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
Pay: $32.00 - $34.33 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
