Grievances & Appeals Nurse Specialist Needed in Orange, CA

Company: Judge Healthcare
Location: Orange
Posted on: May 8, 2022

Job Description:

Case Management opening in Orange, California. This and other rn jobs brought to you by NursingJobCafe.com

Grievances & Appeals nurse specialist needed in Orange, CA!


Position Responsibilities

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• 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
  
  
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  • RN 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:
    
    
    
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    • 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.
      
      
      
      
      
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