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Grievance & Appeals Nurse Specialist

Company: Sunshine Enterprise USA LLC
Location: Orange
Posted on: April 2, 2024

Job Description:

Company Overview: Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.Job Summary: The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals. Duration: Up to 6 months with a possibility of extensionReports to: Manager Clinic Operations, Grievance & AppealsPosition ResponsibilitiesParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.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 physician reviewers for final determination.Resolves complex and sensitive member issues within established timelines.Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.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.Discusses appeal process, medical decisions and hearing rights with members.Assists members in coordinating their services with providers and communicates the status and outcome to members.Assigns position statements and represents the client's state hearings.Completes other projects and duties as assigned. Possesses the Ability To:Analyze and complete written summaries on clinical cases.Conduct research on standards of practice, regulations and policies and procedures that are relevant to review cases.Communicate issues clearly and timely to members, providers, involved departments or health networks.Organize and manage activities related to processing cases within the department.Establish and maintain effective working relationships with the client's leadership and staff.Communicate clearly and concisely, both orally and in writing.Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment. Experience & EducationHigh School diploma required.Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and/or Quality Management.An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred QualificationsActive Registered Nurse (RN) license to practice in the state of California.Bilingual in English and in one of the following languages: Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese.Knowledge of:Medicare and Medi-Cal health care program regulations.Clinical review processes including how to analyze and research clinical issues.Managed care and health care industries.Appeals and grievance processes. At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits: Competitive pay & weekly paychecks Health, dental, vision, and life insurance 401(k) savings plan Awards and recognition programs Benefit eligibility is dependent on employment status. SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment. Compensation details: 40.87-67.82 Hourly WagePI3808896d7d25-25660-34077107

Keywords: Sunshine Enterprise USA LLC, Orange , Grievance & Appeals Nurse Specialist, Healthcare , Orange, California

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