L.A. Care Health Plan
Customer Solution Center Appeals and Grievances Nurse Specialist RN II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Customer Solution Center Appeals and Grievances Nurse Specialist RN II
Job Category:
ClinicalLocation:
Los Angeles, CA, US, 90017Position Type:
Full TimeRequisition ID:
11547Salary Range:
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE:
This position will work
Tuesday - Saturday, 7 a.m. to 4 p.m. PST , with rotating holidays.
At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we ensure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.Job Summary
The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members with health care access or benefit coordination issues, ensuring that clinical grievances, complaints, and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS), and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS) Medi-Cal/Medicare, or commercial insurance.Duties
Conducts intake/triage and appropriate classification of Clinical A&G and Pharmacy requests, making accurate judgments on appeals, grievances, Provider Claim Disputes, medical records, or other issues, and follows procedures on how to handle each type of request and route to the appropriate area within the department.Investigates and resolves clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigates and resolves clinical Provider Complaints/Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identifies Expedited Cases and resolves them within 72 hours.Works with external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Processes the case through to effectuation and final case documentation in the A&G system of record.Investigates and prepares State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).Conducts reviews and presents to physicians provider disputes based on medical necessity reviews. Prepares authorizations after approval by the Medical Director.When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps. Sends written notifications to appropriate parties when necessary. All interactions, including verbal outreach and written communication, will be documented in the A&G system of record.Participates in inter-rater reliability training and assessments.Performs other duties as assigned.Education Required
Associate's Degree in NursingEducation Preferred
Bachelor's Degree in NursingExperience
Required:
At least 5 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment.Skills
Required:Excellent interpersonal and communication skills.Computer literacy and adaptability to computer learning.Time management and priority setting skills.Must be organized and a team player.Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.Good working knowledge of regulatory requirements/standards.Licenses/Certifications Required
Registered Nurse (RN) - Active, current, and unrestricted California LicenseLicenses/Certifications Preferred
Required Training
Physical Requirements
LightAdditional Information
This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental, and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Nursing, Registered Nurse, Medicare, Medicaid, Pharmacy, Healthcare
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Job Category:
ClinicalLocation:
Los Angeles, CA, US, 90017Position Type:
Full TimeRequisition ID:
11547Salary Range:
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE:
This position will work
Tuesday - Saturday, 7 a.m. to 4 p.m. PST , with rotating holidays.
At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we ensure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.Job Summary
The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members with health care access or benefit coordination issues, ensuring that clinical grievances, complaints, and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A. Care, Centers of Medicare and Medicaid Services (CMS), and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, Fee for services (FFS) Medi-Cal/Medicare, or commercial insurance.Duties
Conducts intake/triage and appropriate classification of Clinical A&G and Pharmacy requests, making accurate judgments on appeals, grievances, Provider Claim Disputes, medical records, or other issues, and follows procedures on how to handle each type of request and route to the appropriate area within the department.Investigates and resolves clinical member complaints (grievances/appeals) utilizing all regulatory requirements. Investigates and resolves clinical Provider Complaints/Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA). Identifies Expedited Cases and resolves them within 72 hours.Works with external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.Prepares resolved complaint files for Centers for Medicare and Medicaid Services (CMS), DMHC, and external review organization (QIO or IRE). Processes the case through to effectuation and final case documentation in the A&G system of record.Investigates and prepares State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).Conducts reviews and presents to physicians provider disputes based on medical necessity reviews. Prepares authorizations after approval by the Medical Director.When necessary, outreaches to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps. Sends written notifications to appropriate parties when necessary. All interactions, including verbal outreach and written communication, will be documented in the A&G system of record.Participates in inter-rater reliability training and assessments.Performs other duties as assigned.Education Required
Associate's Degree in NursingEducation Preferred
Bachelor's Degree in NursingExperience
Required:
At least 5 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment.Skills
Required:Excellent interpersonal and communication skills.Computer literacy and adaptability to computer learning.Time management and priority setting skills.Must be organized and a team player.Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.Good working knowledge of regulatory requirements/standards.Licenses/Certifications Required
Registered Nurse (RN) - Active, current, and unrestricted California LicenseLicenses/Certifications Preferred
Required Training
Physical Requirements
LightAdditional Information
This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental, and VisionWellness ProgramNearest Major Market:
Los AngelesJob Segment:
Nursing, Registered Nurse, Medicare, Medicaid, Pharmacy, Healthcare
#J-18808-Ljbffr