Grievance & Appeals Nurse (Remote)

Inland Empire Health Plan•, CA

1d•$63,898 - $83,075•Remote

About The Position

The Grievance & Appeals Nurse works with IPAs, hospitals, internal IEHP departments, and the grievance team to ensure grievance and appeal cases are processed in accordance with IEHP policies and procedures, applicable state and federal regulations, and NCQA requirements. The role coordinates member care with the member’s PCP, IPA, and IEHP team members to support continuous quality care and quality initiatives. The nurse serves as a resource to IEHP personnel and external practitioners and providers, and may triage and assign cases to ensure timely handling and regulatory compliance. The position provides clinical oversight and review of grievance and appeal cases, supports investigations and resolution of member concerns, and maintains documentation required by external agencies. It also contributes to IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation. The position is telecommute-based, with periodic required reporting to IEHP’s main campus for meetings or other business needs, and includes automobile travel within the Inland Empire.

Requirements

At least two years of case management, utilization management in a managed care setting, or related experience in a health care delivery setting.
High school diploma or GED.
Active, unrestricted, and unencumbered California Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians.
Valid California driver’s license.
Working knowledge of member and provider legal rights to access the grievance and appeals resolution process through provider organizations, DHCS, DMHC, CMS, and IEHP.
Working knowledge of outside agencies and resources such as CCS, CMS, DMHC, and DHCS.
Working knowledge of regulatory guidelines for grievances and appeals under CMS, DHCS, DMHC, and NCQA.
Knowledge of microcomputer applications, including spreadsheet, database, and word processing software.
Excellent written and verbal communication skills.
Ability to demonstrate critical thinking and strong problem-solving skills.
Commitment to incorporating LEAN principles into daily work.
Strong attention to detail.
Ability to prioritize work to meet project deadlines.
Ability to escalate issues effectively according to established protocols.
Positive attitude and ability to work in a team setting.

Nice To Haves

Experience in an HMO or managed care setting.
Associate’s degree from an accredited institution.

Responsibilities

Manage grievance and appeal cases in compliance with state and federal guidelines, including CMS requirements.
Ensure team cases are processed thoroughly and timely in accordance with IEHP policies, procedures, and regulatory guidelines.
Ensure member grievance issues are investigated and care is coordinated appropriately.
Work with the Grievance and Appeals Team and departments including Member Services, Provider Services, Compliance, and Medical Services, as well as DMHC, DHCS, and CMS, to review grievance issues.
Review case coding for accuracy and help resolve member medical issues and coordinate care with practitioners, providers, and other involved entities.
Resolve medical grievances with IEHP staff, Grievance Management, and providers as applicable.
Identify case issues, support quality initiatives, refer cases to outside agencies, identify system issues, and refer matters to appropriate IEHP team members.
Help interpret departmental policies, procedures, regulations, benefits, and processes for IEHP members.
Serve as a grievance and appeals subject matter resource for clinical and non-clinical team members and help expedite outstanding issues.
Maintain grievance and appeals documentation according to external agency requirements and provide resources to IEHP departments and Grievance & Appeals Team members.
Notify management of trends involving contracted practitioners and providers that may affect continuity of care.
Provide clinical oversight of assigned cases, including final nurse review of non-Quality-of-Care cases and investigation of Quality-of-Care cases for review by an IEHP Medical Director and designated Nurse Reviewer.
Perform initial medical review and clinical oversight of received team cases.
Ensure necessary follow-up is assigned for completion by designated MedHOK business partners.
Prepare written correspondence to providers, members, and regulatory entities using approved templates and appropriate grammar and punctuation.
Support departmental protocols and goals and the organization’s vision.
Triage new cases for medical urgency and potential need for Organizational Determination, and notify the Immediate Needs team to support timely resolution.
Conduct Quality Assurance Reviews of new cases for correct classification, categorization, documentation, and priority; identify and open additional necessary cases.
Audit daily reports to verify cases are captured and opened within regulatory timeframes and maintain the case log.
When designated, assign new grievance and appeal cases to the appropriate team for investigation and resolution.
Comply with mandated reporting obligations and report allegations of physical and sexual abuse to appropriate authorities as the first line.
Prepare recommendations to uphold or deny appeals using appropriate hierarchy criteria and forward them to the Medical Director for approval.
Prepare files for Grievance and Appeals Committee reviews.
Perform other duties required to support health plan operations and department business needs.