Do you want to work with a team who values both professional and personal growth while also receiving fantastic benefits? We are looking for an Appeals and Grievances Nurse to work remotely with Health Plan of San Joaquin who has strong clinical skills and a passion to help fulfill our mission to continuously improve the health of our community.
WHAT YOU WILL BE DOING
Under general supervision, the Grievance and Appeals Nurse is responsible for investigating and processing grievances and appeals requests in compliance with internal and external requirements, and HPSJ strategies and objectives. Work is varied and moderately complex and requires a limited degree of discretion and independent judgment.
- Conducts investigations and reviews of member grievances and appeals.
- Reviews prospective, concurrent or retrospective medical records of denied services for medical necessity.
- Prepares and distributes case reviews, and recommendations as appropriate, to internal and external reviewers.
- Generates appropriate written correspondence to providers, members, and regulatory entities; collaborates with internal and external stakeholders to ensure reporting and letters are timely and accurate.
- Reviews member and practitioner Notice of Action letters to ensure regulatory compliance; documents findings and escalates as necessary.
- Investigates and perform clinical review of the IMR/SFH’s, submit health plan responses for IMR/SFH’s and participate in SFH’s as directed.
- Documents and maintains activities and records in appropriate HPSJ system(s) according to standards.
Required Skills
REQUIRED SKILLS
WHAT YOU BRING
Knowledge, Skills, Abilities and Competencies
Required
- Strong clinical skills as defined in California scope of practice guidelines for LVN’s.
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Ability to read, interpret and apply written regulations, guidelines and other materials; ability to read and interpret clinical information.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong analytical, assessment and problem-solving skills.
- Strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; includes the ability to effectively explain complex information.
- Ability to collaborate and work as part of a team.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Ability to enter data into and navigate through multiple databases.
- Strong customer service skills.
- Basic mathematics skills, including basic algebra.
- Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion.
Preferred
- Knowledge of Medi-Cal terminology, coding, acronyms, and general Medi-Cal procedures.
- Basic knowledge of the principles and practices of managed care.
- Basic knowledge of Medi-Cal and/or Medicare regulations as they apply to the appeal process.
Required Experience
REQUIRED EXPERIENCE
WHAT YOU HAVE:
Education & Experience
Required
- Graduation from an accredited nursing school; and
- At least three years clinical experience as an LVN in a healthcare setting.
Preferred
- Experience working in managed care, and with Medi-Cal or/or Medicare populations.
Licenses, Certifications
- Unrestricted California Vocational Nurse license; or
- Unrestricted Registered Nurse license.