Customer Solution Center Appeals and Grievances Nurse Specialist RN II
Company: L.A. Care Health Plan
Location: Los Angeles
Posted on: November 6, 2024
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Job Description:
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days) to receive an alert: Customer Solution Center Appeals and
Grievances Nurse Specialist RN II Job Category: - Clinical
Location: - Los Angeles, CA, US, 90017 Position Type: - Full Time
Requisition ID: - 11675 Salary Range: - -$88,854.00 -(Min.) -
-$115,509.00 -(Mid.) - -$142,166.00 -(Max.)PLEASE NOTE: This
position will work -Wednesday - Sunday, 7 a.m. to 4 p.m. PST, with
rotating holidays.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 make sure 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.
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The Customer Solution Center Appeals and Grievances (A&G) Nurse
Specialist Registered Nurse (RN) II provides direct assistance to
member's 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 and makes accurate judgment on appeal,
grievance, 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. Investigation,
and resolution of clinical member complaints (grievances/appeals)
utilizing all regulatory requirements. Investigation, and
resolution of clinical Provider Complaints/ Provider Data
Resolution (PDR) (grievances/appeals) utilizing regulatory and
internal guidelines and Service Level Agreement (SLA).
Identification of Expedited Cases and resolution within 72 hours.
Works with the 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). Process the case thru to
effectuation and final case documentation in the A&G system of
record. Investigation and preparation of 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 which would be 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. In instances where
necessary, sends written notifications to appropriate parties. All
interactions including verbal outreach and written communication
will be documented in the A&G system of record. Participates
inter-rater reliability training and assessments. Perform other
duties as assigned. Education Required Associate's Degree in
Nursing Education Preferred Bachelor's Degree in Nursing
ExperienceRequired: 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 License Licenses/Certifications
PreferredRequired TrainingPhysical Requirements Light Additional
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
Nearest Major Market: Los Angeles
Job Segment: Nursing, Registered Nurse, Medicare, Medicaid,
Pharmacy, Healthcare
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Keywords: L.A. Care Health Plan, Victorville , Customer Solution Center Appeals and Grievances Nurse Specialist RN II, Healthcare , Los Angeles, California
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