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Grievance & Appeals Nurse Specialist

Company: Sunshine Enterprise USA LLC
Location: Orange
Posted on: April 3, 2024

Job Description:

Grievance & Appeals Nurse SpecialistCompany 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 extensionPosition Responsibilities

  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • 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.
  • 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.
  • Oversees state hearing cases, assigns position statements, and represents the client at state hearings.
  • 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.
  • Participates in departmental meetings, trainings, and audits as requested.
  • Assists with the notification process to members or providers on the clinical decision issued.
  • Completes other projects and duties as assigned.Experience & Education
    • High 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 Qualifications
      • Active 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, or Vietnamese.Knowledge & Abilities:
        • Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds.
        • Work independently and exercise sound judgment.
        • Communicate clearly and concisely, both orally and in writing.
        • Work a flexible schedule; available to participate in evening and weekend events.
        • Organize, be analytical, problem-solve and possess project management skills.
        • Work in a fast-paced environment and in an efficient manner.
        • Manage multiple projects and identify opportunities for internal and external collaboration.
        • Motivate and lead multi-program teams and external committees/coalitions.
        • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.Physical Requirements (With or Without Accommodations):- Ability to visually read information from computer screens, forms and other printed materials and information.- Ability to speak (enunciate) clearly in conversation and general communication.- Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.- Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.- Lifting and moving objects, patients and/or equipment 10 to 25 poundsAt 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: 41-67 Hourly WagePI70f8ad5ef748-31181-34161641

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

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