Customer Solution Center Appeals and Grievances Nurse Specialist LVN II
2 days ago
Job Category: Clinical
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11735
Salary 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. Our mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities.
The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance (A&G) 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.
Duties- Work with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances.
- Prepare Nurse Summary for MD review and determination.
- Perform clinical review of medical records related to grievances and appeals.
- Handle member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.
- Review grievance cases that require immediate clinical quality of care.
- Investigate Provider Disputes/PDR and prepare clinical summary for Medical Director determination.
- Work with external providers and Participating Physician Group (PPGs) representatives to obtain relevant medical records and communication documentation.
- Investigate and prepare State Fair Hearing cases as assigned.
- Prepare complaint files for Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DMHC), and 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.
- Outreach to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps as needed.
- Participate in inter-rater reliability training and assessments.
- Perform other duties as assigned.
Associate's Degree. In lieu of degree, equivalent education and/or experience may be considered.
ExperienceRequired: At least 4 years of clinical nurse and managed care experience.
SkillsRequired:
- 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.
Licensed Vocational Nurse (LVN) - Active, current and unrestricted California License.
Physical RequirementsLight
Additional InformationThis 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.
L.A. Care offers a wide range of benefits including:
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
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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, we make...
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Los Angeles, United States L.A. Care Health Plan Full timeJob Summary The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance (A&G) 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...
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Los Angeles, CA, United States L.A. Care Health Plan Full timeCustomer Solution Center Appeals and Grievances Specialist II Job Category: Customer Service Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11505 Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of...
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