Grievances & Appeals Nurse Specialist Needed in Orange, CA (LPN/LVN #)
Company: Judge Healthcare
Posted on: May 1, 2021
Grievances & Appeals nurse specialist needed in Orange, CA!
- 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
- Analyzes and reports cases through GARS' subcommittee.
- Participates in departmental meetings, trainings and audits as
- 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
- Prepares position statements and represents Client at State
Experience & Education
- LVN license to practice in the State of California
- 5 years of health care experience required; preferably in a
managed care environment in related area of responsibility.
- Medicare and Medi-Cal health care program regulations.
- Clinical review processes including how to analyze and research
- Managed care industry, health care, appeals and grievance
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Keywords: Judge Healthcare, Orange , Grievances & Appeals Nurse Specialist Needed in Orange, CA (LPN/LVN #), Healthcare , Orange, California
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