Grievance & Appeals Regulatory Nurse

Inland Empire Health Plan

6d•Hybrid

About The Position

Reporting to the Grievance & Appeals Regulatory Manager, the Grievance & Appeals Regulatory Nurse is responsible for working directly with providers, delegated entities, and internal IEHP departments in investigating and resolving cases, and responding to regulatory agencies to ensure compliance with internal Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations. This position coordinates member care in conjunction with the member's Providers to provide continuous quality care and assist in the development of quality initiatives. The Grievance & Appeals Regulatory Nurse serves as a resource to IEHP personnel and providers. Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Three (3) or more years of experience with 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 required
Experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar) required
Experience in either State Fair Hearing (SFH) or Appeals or Grievances referred
High School Diploma or GED required
Obtain Center for Medicare and Medicaid Services (CMS) Annual Certification within six (6) months of hire
Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required
Generate written correspondence using appropriate grammar and punctuation
Microcomputer applications: spreadsheet, database, and word processing required
Excellent written and verbal communication skills
Proven ability to: Demonstrate critical thinking, good judgment, and strong problem-solving capability Prioritize work to ensure adherence to project deadlines Effectively escalate issues as identified, following established protocols Demonstrate a commitment to incorporate LEAN principles into daily work Show strong attention to detail Possess a positive attitude and ability to work in a team setting Exhibit flexibility in job roles and responsibilities Express a strong drive to “do the right thing” and adhere to IEHP Mission, Vision and Values

Nice To Haves

Advanced professional reporting experience within Microsoft Excel preferred
Experience preparing professional, data driven narrative reports for all staff levels preferred
Legal processing experience preferred
Bachelor's degree in a Health-related field from an accredited institution preferred
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN preferred
Valid California Driver's License preferred
Knowledge of outside agencies and resources such as: CCS, CMS, DMHC, and DHCS
Knowledge of applicable laws, regulations, Welfare & Institution codes, assembly bills and All Plan Letters that are affiliated with the IEHP's managed care setting