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Customer Solution Center Appeals and Grievances Nurse Specialist LVN II
3 months ago
Salary Range: $67, Min.) - $87, Mid.) - $107, Max.)
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 in five health plans, 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.
The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance program for L.A. Care Health Plan members under the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director. This position provides assistance to members with health care access and benefit coordination issues, ensuring that clinical grievances and complex issues are investigated and resolved to the member's satisfaction consistent with L.A. Care Health Plan and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care Health Plan Lines of Business.
DutiesWorks with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.
Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.
Investigates Provider Disputes/PDR and prepares clinical summary for Medical Director determination.
Work with the external providers and PPGs representatives to obtain relevant medical records and communication documentation.
Investigation and preparation of State Fair Hearing cases as assigned.
Prepare resolved complaint files for Centers for Medicare and Medicaid Services(CMS), external review organization (QIO or IRE).
Work with Utilization Management and PNO to facilitate completion of resolution determination.
Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.
Perform other duties as assigned.
Duties ContinuedEducation Required
Associate's DegreeIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred
Experience
Required:
At least 4 years of clinical nurse and managed care experience.
Required:
Excellent interpersonal and communication skills.
Good working knowledge of regulatory requirements/standards.
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 business units, Plan Partners, participating provider groups, and external agencies.
Licenses/Certifications RequiredLicensed Vocational Nurse (LVN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred
Required Training
Required:
License Vocational Nursing (LVN)
LightAdditional Information
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 Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
