Grievance and Appeals Nurse (LVN)
About the position
The Grievance and Appeals Nurse (LVN) at Kinetic Personnel Group is responsible for managing grievance cases within a public health plan. This role involves coordinating care with various stakeholders, ensuring compliance with regulatory guidelines, and serving as a resource for both internal and external parties. The position operates in a hybrid work environment, allowing for both remote and in-office work, and focuses on maintaining high standards of care and quality initiatives.
Responsibilities
Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
,
Understand Member and Provider legal rights to access grievance resolution process.
,
Ensure compliance with state and federal guidelines including CMS requirements.
,
Work closely with the Grievance & Appeals Team to investigate and coordinate care for Member grievances and appeals.
,
Triage new cases to identify medical urgency and notify Immediate Needs team for timely resolution.
,
Complete Quality Assurance Reviews on all new Grievance & Appeal cases.
,
Audit daily reports to assure all Grievance & Appeal cases are captured and opened within regulatory timeframes.
,
Assign new Grievance & Appeal cases to appropriate team for investigation and resolution.
,
Comply with mandated reporting obligations for allegations of abuse.
,
Review case coding for accuracy and assist in resolution of Member medical issues.
,
Identify case issues and assist in developing quality initiatives.
,
Prepare recommendations to uphold or deny appeals for Medical Director approval.
,
Prepare files for Appeals Committee reviews.
,
Serve as subject matter expert for appeals and assist clinical and non-clinical Team Members.
,
Notify Grievance & Appeals Management of trends related to contracted practitioners.
,
Conduct initial medical review and clinical oversight of received team cases.
,
Support protocols and goals of department and organization.
Requirements
Possession of a high school diploma or equivalent.
,
Active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN.
,
Two (2) years or more case management or utilization management experience in a managed care setting.
,
Knowledge of outside agencies and resources such as CCS, CMS, DMHC.
,
Valid California Driver's License.
Nice-to-haves
Experience in Grievance & Appeals (2 years preferred).
,
Experience in Utilization management (2 years required).
Benefits
Health insurance
,
Dental insurance
,
Vision insurance
Apply Now
The Grievance and Appeals Nurse (LVN) at Kinetic Personnel Group is responsible for managing grievance cases within a public health plan. This role involves coordinating care with various stakeholders, ensuring compliance with regulatory guidelines, and serving as a resource for both internal and external parties. The position operates in a hybrid work environment, allowing for both remote and in-office work, and focuses on maintaining high standards of care and quality initiatives.
Responsibilities
Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
,
Understand Member and Provider legal rights to access grievance resolution process.
,
Ensure compliance with state and federal guidelines including CMS requirements.
,
Work closely with the Grievance & Appeals Team to investigate and coordinate care for Member grievances and appeals.
,
Triage new cases to identify medical urgency and notify Immediate Needs team for timely resolution.
,
Complete Quality Assurance Reviews on all new Grievance & Appeal cases.
,
Audit daily reports to assure all Grievance & Appeal cases are captured and opened within regulatory timeframes.
,
Assign new Grievance & Appeal cases to appropriate team for investigation and resolution.
,
Comply with mandated reporting obligations for allegations of abuse.
,
Review case coding for accuracy and assist in resolution of Member medical issues.
,
Identify case issues and assist in developing quality initiatives.
,
Prepare recommendations to uphold or deny appeals for Medical Director approval.
,
Prepare files for Appeals Committee reviews.
,
Serve as subject matter expert for appeals and assist clinical and non-clinical Team Members.
,
Notify Grievance & Appeals Management of trends related to contracted practitioners.
,
Conduct initial medical review and clinical oversight of received team cases.
,
Support protocols and goals of department and organization.
Requirements
Possession of a high school diploma or equivalent.
,
Active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN.
,
Two (2) years or more case management or utilization management experience in a managed care setting.
,
Knowledge of outside agencies and resources such as CCS, CMS, DMHC.
,
Valid California Driver's License.
Nice-to-haves
Experience in Grievance & Appeals (2 years preferred).
,
Experience in Utilization management (2 years required).
Benefits
Health insurance
,
Dental insurance
,
Vision insurance
Apply Now