Managed Care Nurse Grievance System Coordinator - Remote Position!

DOCS Management Services•Coos Bay, OR

25d•$34 - $50•Remote

About The Position

We are currently hiring a REMOTE Nurse Grievance System Coordinator ! If you are organized, have excellent communication skills, work well under pressure and tight deadlines, and value being part of a team that makes a difference, you may be the right person for the position! Apply today! JOB SPECIFICATIONS Classification: NON-EXEMPT | Status: PART-TIME, 28-HOURS/WEEK, Business Operations are Monday - Friday, generally 8am to 5pm, Pacific Time Salary: $34 - $50/HOURLY Department: Grievance & Appeals | Work Location: REMOTE, local to Oregon Reports to: Chief Compliance & Quality Officer Supervision Exercised: Non-supervisory Job Purpose: Grievance System Clinical Coordinator This position is responsible for supporting the operations of the Grievance System by preparing clinically informed case files for review by physician-level decision-makers. Responsibilities include gathering and organizing medical records, treatment history, prior authorization data, and applicable clinical guidelines to ensure thorough and timely case preparation. The role also includes coordinating the intake and resolution of member complaints and ensuring timely processing of grievances and appeals in compliance with all regulatory requirements. This position helps maintain adherence to required timelines under 42 CFR §438, Oregon Health Authority (OHA) contractual obligations, and Section 1557 of the Affordable Care Act (ACA), ensuring members receive appropriate, equitable, and timely responses to their concerns.

Requirements

Current, unrestricted Oregon nursing license, RN strongly preferred, willing to consider LPN with strong clinical background
Minimum three years’ experience in managed care or other healthcare setting
Three years’ experience investigative, reporting, or information analysis required
A high level of technological proficiency, including the ability to navigate multiple software platforms simultaneously and quickly learn new systems and tools as needed, is required

Nice To Haves

Bilingual preferred, qualified, certified, or willing to obtain
Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred

Responsibilities

Grievance System Clinical Coordination Responsible for creating and maintaining positive relationships between the CCO, its members, and providers, by promoting clear communication and equitable resolution of concerns.
Manage the grievance and appeals process from intake to resolution, including triage, investigation, and closure, in compliance with 42 CFR §438.400–438.424, OHA CCO contract requirements, and internal policies.
Gather and analyze comprehensive documentation from internal systems (e.g., authorizations, claims, care coordination notes) and external sources (e.g., provider records) relevant to grievances and appeals.
Clinically contextualize appeal requests by summarizing medical records, treatment timelines, prior authorization and claims decisions, and clinical guidelines for submission to Physician Reviewers.
Maintain a current working knowledge of Oregon Health Plan (OHP) benefits, medical necessity criteria, covered services, and CCO-specific clinical programs.
Develop and maintain grievance and appeal policies and procedures, including those governing clinical file preparation, ensuring OHA approval and regulatory alignment.
Collaborate with internal departments (Utilization Management, Customer Service, Claims) and external delegates to ensure consistent application of grievance and appeal procedures.
Use internal tools and systems (e.g., claims systems, EHRs, case tracking software) to conduct investigations, verify eligibility, manage notification timeframes, and confirm plan benefits and authorizations.
As applicable, assist in the preparation and tracking of medical records and member information release forms needed to process complaints and appeals or support administrative hearings.
Apply clinical and critical thinking skills to correctly categorize appeal types (e.g., adverse benefit determinations, expedited requests), determine review pathways, and ensure appropriate reviewers are engaged.
Ensure all grievance and appeal documentation is complete, accurate, and compliant, including case categorization, authorization adjustments, and timely claims routing.
Draft, review, and issue member and provider correspondence in accordance with OHA and federal timeframes, ensuring language access requirements under ACA Section 1557 are met.
Work independently under time-sensitive conditions to ensure timely closure of grievance and appeal cases in accordance with CCO, OHA, and CMS standards.
Prepare complete and well-organized case files for internal audits and administrative hearings.
Support member and provider education on grievance and appeal rights and procedural steps, including explanation of clinical determinations when applicable.
Maintain professional and objective communication with all stakeholders involved in complaints and appeals, including medical providers, members, and external reviewers.
Translate complex information related to clinical decisions, benefit denials, and regulatory requirements into clear, accessible language for internal staff and external partners.
Provide regular case trend reports to the Chief Medical Officer (CMO) and Chief Operating Officer (COO), including clinical insights, escalation themes, and recommendations for quality improvement.
Uphold strict confidentiality and compliance with HIPAA, CFR, and CCO guidelines in handling protected health information (PHI) and sensitive case data.
Monitor and report suspected fraud, waste, or abuse per company policy and contractual obligations, particularly in cases involving clinical service disputes.
Adhere to all applicable CCO, state, and federal policies and procedures related to grievance and appeals operations, clinical case documentation, and nondiscrimination (including ACA Section 1557).
Perform other duties as assigned that support the goals of equitable, timely, and member-centered resolution of grievances and appeals.
Participate in quality and organizational process improvement activities and teams when requested
Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
Handle confidential information and materials appropriately and maintain a secure work area
Other duties as assigned
Participate in quality and organizational process improvement activities when requested
Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
Advance personal knowledge base by pursuing continuing education to enhance professional competence
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
Represent organization at meetings and conferences as applicable