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Grievances & Appeals Nurse Specialist Needed in Orange, CA (LPN/LVN #)

Company: Judge Healthcare
Location: Orange
Posted on: May 1, 2021

Job Description:

Grievances & Appeals nurse specialist needed in Orange, CA!
Position Responsibilities

  • Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
  • Presents recommendations based on clinical review, criteria and organizational policies to Client's physician reviewers for final determination.
  • Analyzes and reports cases through GARS' subcommittee.
  • Participates in departmental meetings, trainings and audits as requested.
  • Oversees state hearing cases.
  • Assists with the notification process to members or providers on the clinical decision issued.
  • Discuss appeal process, medical decisions and hearing rights with members.
  • Prepares position statements and represents Client at State Hearings.
    Experience & Education
    • LVN license to practice in the State of California required
    • 5 years of health care experience required; preferably in a managed care environment in related area of responsibility.
      Knowledge of:
      • Medicare and Medi-Cal health care program regulations.
      • Clinical review processes including how to analyze and research clinical issues.
      • Managed care industry, health care, appeals and grievance processes.
        Keyphrases: medical case management jobs, case manager jobs, case manager consultant jobs, case management consultant jobs, geriatric case management jobs, case management nursing jobs, nurse case manager jobs

Keywords: Judge Healthcare, Orange , Grievances & Appeals Nurse Specialist Needed in Orange, CA (LPN/LVN #), Healthcare , Orange, California

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