Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

L.A. Care Health Plan • Los Angeles, CA

118d • $117,509 - $188,015

About The Position

The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement. This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals.

Requirements

• Bachelor's Degree in Nursing.
• 6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment.
• At least 3 years of management level operations leadership experience.
• Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations.
• Experience building relationships with organizations and business partners.

Nice To Haves

• Managed care experience.

Responsibilities

• Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members.
• Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.
• Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances.
• Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries.
• Responsible for timely daily operations in the A&G Clinical Services Unit and other general operations units.
• Ensure timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc.
• Collaborate with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refer to community partners as appropriate.
• Lead, participate and provide representation of the A&G Team at Internal and External meetings/workgroups.
• Develop and execute on strategic opportunities to improve the overall appeals & grievance process.
• Create a best in clinical appeals process that is efficient and effective in managing member appeals.
• Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships.
• Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.
• Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.
• Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management.
• Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department.
• Manage staff, including monitoring of day to day activities of staff, performance, mentoring, training, and handling of questions or issues raised by staff.

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees