Grievance and Appeals Nurse Specialist

4 days ago

Rancho Cucamonga, California, United States Alura Workforce Solutions Full time
Job Summary

We are seeking a highly skilled and experienced Grievance and Appeals Nurse to join our team at Alura Workforce Solutions. As a key member of our healthcare team, you will be responsible for ensuring that grievance and appeal cases are processed in accordance with regulatory guidelines and company policies.

Key Responsibilities
  • Work closely with internal departments, IPAs, hospitals, and external agencies to ensure timely and compliant resolution of grievance and appeal cases.
  • Coordinate care of members in conjunction with PCPs, IPAs, and company team members to provide continuous quality care and support quality initiatives.
  • Serve as a resource person to company personnel, external practitioners, and providers, providing guidance on regulatory guidelines and company policies.
  • Triage new cases to identify medical urgency and potential need for Organizational Determination, notifying the Immediate Needs team for timely resolution.
  • Complete Quality Assurance Reviews on all new grievance and appeal cases, ensuring correct classification, categorization, and documentation of dates, source, line of business, requestor, and priority.
  • Audit daily reports to ensure all grievance and appeal cases are captured and opened within regulatory timeframes, maintaining a log of all cases opened and/or reviewed.
  • Assign new grievance and appeal cases to the appropriate team for investigation and resolution, complying with mandated reporting obligations and serving as the first line to report allegations of physical and sexual abuse to the appropriate authorities.
  • Prepare recommendations to uphold or deny appeal using appropriate criteria hierarchy and forward to Medical Director for approval, preparing files for Grievance and Appeals Committee reviews.
  • Serve as a subject matter expert for grievance and appeals, providing guidance to clinical and non-clinical team members in expediting the resolution of outstanding issues, maintaining all grievance and appeals documentation according to external agency requirements.
Requirements
  • Two (2) years or more case management, utilization management in a managed care setting or related experience in a healthcare delivery setting.
  • Experience in an HMO or experience in a managed care setting preferred.
  • High school diploma or GED required.
  • Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required.
  • Drivers License Required.
  • Yes, must have a valid California Driver's License.
  • Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS.
  • Ability to effectively escalate issues as identified, following established protocols.
  • Positive attitude and ability to work in a team setting.

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