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    Grievance and Appeals Nurse Specialist - Redding, United States - Partnership HealthPlan of California

    Partnership HealthPlan of California
    Partnership HealthPlan of California Redding, United States

    3 weeks ago

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    Description

    Overview:

    Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance and
    appeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of cases
    to ensure members receive high quality healthcare services. Working closely with PHC Medical
    Directors, oversees assessments for medically necessary determinations, quality of care
    concerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadership
    to Grievance & Appeals Case Analysts to ensure clinical solution followed on casework.
    Ensures casework complies with DHCS guidelines, NCQA standards, and PHC best practices.
    Works independently, prioritizes case deliverables, remains customer-focused and stays current
    on changes in the healthcare system that may trigger member dissatisfaction. This position is
    eligible for teleworking.

    Responsibilities:
    • Assesses all cases to determine if members have any emergent or immediate
      medical needs. Identifies potential quality of care, fraud, waste, and abuse issues.
      Takes appropriate actions.
    • Executes independent clinical judgement in assessing members concern, care and
      treatment. Evaluates and solves for any deviations in the standard of care,
      regulations, policy and procedures relevant to assigned cases.
    • Conducts comprehensive clinical assessments as they relate to a members
      physical, psychosocial, environmental, safety, developmental, cultural and linguistic
      needs. Takes appropriate actions.
    • In coordination with the Grievance & Appeal Case Analyst, may contact members as
      it directly relates to their immediate clinical concerns. May refer to Care Coordination
      for continued/ongoing case management.
    • Assesses and formally classifies disputed benefits according to NCQA pre-service
      and post-service classifications.
    • Provides guidance to determine if/which medical records are needed to thoroughly
      evaluate the substance of on grievance and appeal cases.
    • Evaluates all received medical records and writes clinical summary of observations
      in preparation of MD Directors review. Medical records average pages per
      case.
    • Works closely with Grievance & Appeal Case Analyst, ensuring clinical content of
      resolution letters reflect clinical accuracy and medical terms are written in layman
      language
    • Responsible for end-to-end investigation of exempt grievances. Works closely with
      PHC Medical Directors to identify and address concerns related to quality of care,
      HIPAA violations, fraud, waste, or abuse activity.
    • Documents all casework activity thoroughly, accurately, timely, and ethically.
    • Manages assigned cases so they are completed within DHCS timeframes, according
      to G&A Desktop procedures, and/or as directed by management.
    • Serves as a clinical resource to the Grievance & Appeals team
    • Identifies systematic or recurring issues that create barriers to high quality healthcare
      and reports them to leadership.
    • Can work in a team environment
    • Effective communicator in all modes of communication (e.g., written, verbal)
    • May serve as a backup to absent Grievance & Appeals Nurse Specialists
    • Attends meetings as needed including but not limited to Clinical Case Forum meetings,
      Department Meetings, and Division Meetings
    • Maintains a Registered Nurse licensure in good standing
    • Other duties as assigned.
    Qualifications:

    Education and Experience

    Bachelors degree in Nursing, 3-5 years experience to include at least one
    (1) year of case management experience and one (1) year in an acute
    care setting; or equivalent combination of education and experience. CCM
    desired. Knowledge of PHC Grievance & Appeals processes. General
    knowledge of managed care with emphasis in UM or CM preferred.

    SpecialSkills,Licenses and Certifications

    Current California Registered Nurse license. Critical thinker. Organized.
    Thorough knowledge of utilization and case management programs and
    related criteria and protocols. Experience in managed care business
    practices and ability to access data information using computer systems.
    Ability to work within an interdisciplinary structure and function
    independently in a fast-paced environment while managing multiple
    priorities and meeting deadlines. Strong organizational skills required.
    Effective telephone and computer data entry skills required. Valid
    California drivers license and proof of current automobile insurance
    compliant with PHC policy are required to operate a vehicle and travel for
    company business.

    PerformanceBasedCompetencies

    Excellent written and verbal communication skills with ability to read and
    interpret benefit contract specifications are required. Ability to apply
    clinical judgment to complex medical situations and make quick decisions
    in a fast-paced environment. Works well under pressure and maintains a
    professional composure when interacting with all stakeholders, including
    members.

    Work Environment And Physical Demands

    Daily use of telephone and computer for most of the day. Standard
    cubicle workstation or telecommute eligible. When required, ability to
    move, carry or lift objects weighing up to 25 lbs.

    AllHealthPlan employees are expected to:

    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlans policies and procedures, as they may from time to time be

    HIRING RANGE:

    $ 91, $ 118,514.23

    IMPORTANT DISCLAIMER NOTICE

    Thejobduties,elements,responsibilities,skills,functions,experience,educationalfactorsandthe requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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