Appeals and Grievances Nurse Specialist RN II

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.

At least 5 years of experience in Clinical RN.

At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment.

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.

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.