The Grievance and Appeals Nurse Specialist participates in managing Public Health Plan’s medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures.
This position will start out as a 6-month temporary position, that could lead to a permanent position for the right candidate. A permanent position does include excellent CalPERS pension, 401a (4% contribution) and excellent government benefits and Holiday/PTO schedule.
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
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 Public Health Plan Health’s physician reviewers for final determination.
Resolves complex and sensitive member issues within established timelines.
Maintains departmental database and the integrity of records 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.
Discusses appeal process, medical decisions and hearing rights with members.
Assists members in coordinating their services with providers and communicates the status and outcome to members.
Assigns position statements and represents Public Health Plan Health at state hearings.
Completes other projects and duties as assigned.
Analyze and complete written summaries on clinical cases.
Conduct research on standards of practice, regulations and policies and procedures that are relevant to review cases.
Communicate issues clearly and timely to members, providers, involved departments or health networks.
Organize and manage activities related to processing cases within the department.
Establish and maintain effective working relationships with Public Health Plan Health’s leadership and staff.
Communicate clearly and concisely, both orally and in writing.
Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.
