Grievance and Appeals Nurse Specialist Needed!
Company: HealthCare Talent
Location: Orange
Posted on: February 22, 2021
Job Description:
Grievance and Appeals Nurse Specialist Needed!
- Orange, CA
- Full-time Company Description Healthcare Talent is assisting
our client in hiring a Grievance & Appeals Nurse Specialist. The
ideal candidate will manage the department work activities to
ensure that service standards are met, and operations are
consistent with the health plan policies, as well as the policies
of the regulatory agencies.-- The Grievance and Appeals (GARS)
Nurse Specialist participates in managing the organization's State
Hearing review for all lines of business, including handling
expedited and standard requests and providing oversight of program
assistant/resolution specialists assigned to assist in processing
of the cases. Ensures State Hearing requests are processed in
accordance with regulations, compliance standards and policy and
procedures. Investigation and preparation of Statements of Position
based on clinical information, benefits, applicable regulations
related to member dispute of decisions. Clearly articulates the
facts and company's position regarding dispute to Administrative
Law Judge hearing the case.-- Responsible for the management of the
day-to-day operational activities of the departments, including
review of resolution letters for regulatory requirements. Our
client has a unique business philosophy; their goal is to provide
employees with a place to excel while creating something truly
meaningful in their work. This philosophy has helped them grow into
an award-winning company. Employees are provided with room for
advancement, competitive compensation, and an excellent benefit
package.-- Job Description Position Responsibilities --- Prepares
clinical reviews and provides monitoring of cases involving medical
decisions and quality or care or service, and ensures all cases are
completed in accordance with State and Federal regulatory
requirements for timelines. --- Meets timeframes for performance
with balancing the need to produce high quality work and resolving
complex and sensitive member issues. --- Ensures integrity of
departmental database and recording maintenance by thorough, timely
and accurate entry of cases assigned.-- --- Assists with analyzing
and reporting of cases through the GARS Subcommittee. ---
Participates in departmental meetings, trainings and audits as
requested. --- Oversight of State Hearing cases. --- Assists with
the intake/notification process of cases in the department.-- ---
Prepares position statements and represents company at State Fair
Hearings. --- Other projects and duties as assigned. Possess the
Ability to: --- Analyze and complete written summaries on clinical
cases. --- Conduct research on standards of practice, regulations
and policy and procedures relevant to review cases. --- Provide
oversight and training to staff on GARS procedures and
requirements. --- Communicate issues clearly and timely to members,
providers, involved departments or health networks. --- Organize
and manage activities related to processing cases timely and
accurately within the department and regulatory standards.
Qualifications Required Experience & Education --- Current RN or
LVN License to practice in the State of California. --- 5 years of
health care experience, preferably in a managed care environment in
related area of responsibility, i.e. utilization management,
quality management, grievances and appeals. --- Strong
interpersonal, verbal and written communication skills. --- Strong
problem solving skills, implementing initiatives or projects, and
collaborating with other professional and non-clinical staff.
Knowledge of: --- Medicare, Medi-Cal and Healthy Families health
care program regulations. --- Clinical review processes including
how to analyze and research clinical issues. --- Computer
applications including MS Office suite. --- Business communication
skills. --- The managed care industry, health care processes. ---
Appeals and grievance processes. --- Managed care organizational
operations. Additional Information If you feel that you have the
skills we require, please respond to this posting with your contact
information and your resume in a Word document. We look forward to
hearing from you today!-- Grievance and Appeals Nurse Specialist
Needed!
Keywords: HealthCare Talent, Orange , Grievance and Appeals Nurse Specialist Needed!, Healthcare , Orange, California
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