Appeals & Grievances Nurse Specialist RN
2 weeks ago
Location: Los Angeles, CA (Remote)
Position Type: Contract
Job summary:
• 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 Clients of Medicare and Medicaid Services (CMS) and regulatory guidelines.
• Benefit coordination may involve coordinating multiple Client 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.
• 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.
• Perform other duties as assigned.
Education Required:
• Associate's Degree in Nursing
Education Preferred:
• Bachelor's Degree in Nursing
Experience Required:
• At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/ Medicaid in a managed care/ health plan environment.
• Good working knowledge of regulatory requirements/standards.
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, Client partners, participating provider groups, and other external agencies.
Licenses/Certifications Required:
• Registered Nurse (RN) - Active, current and unrestricted California License
-
Customer Solution Center Appeals and Grievances
2 weeks ago
Los Angeles, United States L.A. Care Health Plan Full timeCustomer Solution Center Appeals and Grievances Nurse Specialist RN II **Job Category**:Clinical**Department**:CSC Appeals & Grievances**Location**:Los Angeles, CA, US, 90017**Position Type**:Full Time**Requisition ID**:10889**Salary Range**: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)- Established in 1997, L.A. Care Health Plan is an...
-
Los Angeles, United States L.A. Care Health Plan Full timeCustomer Solution Center Appeals and Grievances Nurse Specialist RN II **Job Category**:Clinical**Department**:CSC Appeals & Grievances**Location**:Los Angeles, CA, US, 90017**Position Type**:Full Time**Requisition ID**:10886**Salary Range**: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)- Established in 1997, L.A. Care Health Plan is an...
-
Appeals and Grievances Training Specialist
1 week ago
Los Angeles, United States Bright Vision Technologies Full timeBright Vision Technologies has an immediate opportunity for **Appeals and Grievances Training Specialist at Los Angeles, CA, US.** Job Title**:Appeals and Grievances Training Specialist** Job Location**:Los Angeles, CA, US** Job Type**: Hybrid** **Education Required**: Bachelor's Degree in Business Administration or Healthcare Related Field In lieu of...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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...
-
Appeals and Grievances Training Specialist
1 week ago
Los Angeles, United States Business Integra Inc Full timeTitle - Customer Solution Center Appeals and Grievances Training Specialist II Job Type - Hybrid | Permanent Location - Los Angeles, CA (Position will be Hybrid - will be conducting combination WebEx and in near future Onsite Trainings. Person must be flexible. Person will need to be working in state remote when working from home). Required: Must have 3...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, 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...
-
Grievance and Appeals Coordinator
5 days ago
Los Angeles, United States Alinestaffing Full timeA-Line Staffing is now hiring a Grievance and Appeal Coordinator in the Woodland Hills CA area. The Grievance and Appeal Coordinator would be working for a Fortune 500 company and has career growth potential. This would be full time / 40+ hours per week. If you are interested in this Grievance and Appeal Coordinator position, please contact Melissa Ortiz at...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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...
-
Appeals and Grievances Manager
4 days ago
Los Angeles, United States Imperial Health Plan of California, Inc. Full timeJOB SUMMARY: Oversees the department work activities assuring compliance with all regulatory guidelines and policy protocols. Serves as the team leader for the team who receives, investigates, and responds to all member grievances & appeals. Responsible for the overall compliance which include timely and accurate resolutions of grievances & appeals....
-
Appeals and Grievance Coordinator
3 weeks ago
Los Angeles, United States Imperial Health Plan of California, Inc. Full timeJOB TITLE: Appeals and Grievance Coordinator FLSA STATUS: Non-Exempt DEPARTMENT: Appeals and Grievances REPORTS TO: Supervisor, Appeals & Grievances JOB SUMMARY: Responsible for reviewing and resolving member complaints and appeals and communicating resolution to members in accordance with the standards and requirements established by Medicare and...
-
Los Angeles, United States L.A. Care Health Plan Full timeThe Customer Solution Center Appeals and Grievances (A&G) Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in co Solution, Appeals, Specialist, Customer, Technology, Healthcare
-
Appeals & Grievances Training Specialist
1 week ago
Los Angeles, United States Clovity Full time**Job Title**:Customer Solution Center Appeals and Grievances Training Specialist **Position Type**:Position will be Hybrid - will be conducting combination WebEx and in near future Onsite Trainings. Person must be flexible. Person will need to be working in state remote when working from home. **Location**:Los Angeles, CA, US **Job...
-
Appeals and Grievances
8 hours ago
United States, CA, El Dorado Hills Blue Shield of California Full timeYour Role The Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Appeals and Grievances RN Senior will report to the Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of...
-
Grievance & Appeals Coordinator I
5 days ago
Los Angeles, California, United States TEKsystems Full timeHiring for Grievance and appeals Coordinator Tek Systems is currently hiring for Healthcare program coordinators for one of top healthcare company in Florida.Description:Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.Education/Experience: High...
-
Los Angeles, United States Med4Hire Full time**Customer Solution Center Appeal and Grievance Compliance Advisor** **Hybrid** **Position will be hybrid - during audits that are conducted in the year will come on site to collaborate with team. Person must be flexible and ideally live local to Los Angeles. Person must be living in state while working remote.** **Los Angeles, CA,...
-
Manager II Grievance/Appeals
1 week ago
Los Angeles, United States Elevance Health Full timeManager II Grievance/Appeals - Claims Support *Location: CA Residential Requirement This position will work a hybrid model (remote and office). Ideal candidates will live in the state of California within 50 miles of one of our PulsePoint locations. The Manager II Grievance/Appeals is responsible for management oversight of grievances and appeals...
-
Grievance & Appeals Coordinator I
5 days ago
Los Angeles, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must be located in the state of California. This is a remote role. Position...
-
Los Angeles, United States L.A. Care Health Plan Full timeSalary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary 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...
