- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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Nursing specialist
1 week ago
Zenith Ventures El Rio, United StatesThe facilities of Paritätische Altenhilfe offer opportunities for employment in full-time, part-time, or outpatient care. The service to people and their dignified care are at the center. · As a nursing professional at Paritätische Altenhilfe, you will care for elderly people in ...
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Clinical Nurse Specialist
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Cedars-Sinai Los Angeles, CA, United States**Job Description** · **Are you a leader? Do you inspire?** · **A true leader aims to inspire-and at Cedars-Sinai, that's exactly what our Clinical Nurse Specialists (CNS) do Our people bring an unmatched passion to their craft and it shows in everything they accomplish, includin ...
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Clinical Nurse Specialist
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UCLA Health Los Angeles, CA, United StatesGeneral Information · Press space or enter keys to toggle section visibility · Work Location: Los Angeles, USA · Onsite or Remote · Fully On-Site · Work Schedule · 8am-5pm · Posted Date · 01/22/2024 · Salary Range: $ Annually · Employment Type · 2 - Staff: Career · Duration · Ind ...
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Clinical Nurse Specialist
3 days ago
University of California Los Angeles, United StatesThe clinical nurse specialist (CNS) - is the clinical nursing leader for Perianesthesia/ Procedural programs at UCLA Health. The advanced knowledge and skills required for this role include clinical expertise, evidence-based practice, collaboration, consultation, education, mento ...
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Clinical Nurse Specialist
3 days ago
UCLA Health Los Angeles, United States· The clinical nurse specialist (CNS) - is the clinical nursing leader for Perianesthesia/ Procedural programs at UCLA Health. The advanced knowledge and skills required for this role include clinical expertise, evidence-based practice, collaboration, consultation, education, me ...
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clinical nurse specialist
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Los Angeles County (CA) Los Angeles AFB, CA , USA, United StatesPosition/Program Information · DEPARTMENT OF HEALTH SERVICES · EXAM NUMBER: Y5357T · OPEN COMPETITIVE JOB OPPORTUNITY · ORIGINAL POSTING DATE: 1/1/2011 · REBULLETIN INFORMATION: · THIS ANNOUNCEMENT IS A REBULLETIN TO UPDATE THE EXAMINATION CONTENT INFORMATION REGARDING NOTIFICATI ...
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Nursing specialist
1 week ago
BlueSky Innovations Pasadena, United StatesAt advita, our focus is on providing individual care to our clients, without the stress often found in other care facilities. Thanks to well-equipped teams, we are able to dedicate ourselves to the needs of our guests. · We promote a collegial working environment and have simplif ...
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nurse professional development specialist
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Childrens Hospital Los Angeles Los Angeles AFB, CA , USA, United StatesNATIONAL LEADERS IN PEDIATRIC CARE · Ranked among the top 10 pediatric hospitals in the nation, Children's Hospital Los Angeles (CHLA) provides the best care for kids in California. · Here world-class experts in medicine, education and research work together to deliver family-cen ...
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Nursing specialist
1 week ago
NebulaWorks Compton, United StatesCompton Nursing Professional (m/f/d) · Full-time or part-time · Hildburghauser Str., Berlin, Germany · With or without professional experience · Are you interested in working for the largest nursing home operator in Germany? · Are you looking for a crisis-proof employer? · If you ...
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Nursing specialist
1 week ago
Apex Innovations Long Valley, United StatesAbout us: · The Volkssolidarität City Association Leipzig e. V. is the operator of various social institutions and provides supportive, caring, and assisting services with both full-time and volunteer employees. Our range of services includes 15 day care centers, a children's hom ...
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appeals & grievances nurse specialist rn
3 weeks ago
Mitchell Martin Los Angeles, CA , USA, United StatesOur Client, Provides health insurance for low-income individuals, is seeking an Appeals & Grievances Nurse Specialist RN. · Location: Los Angeles, CA (Remote) · Position Type: Contract · Job summary: · • The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist ...
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Appeals & Grievances Nurse Specialist RN
2 weeks ago
Mitchell Martin Los Angeles, United StatesOur Client, Provides health insurance for low-income individuals, is seeking an Appeals & Grievances Nurse Specialist RN. · Location: · Los Angeles, CA (Remote) · Position Type: · Contract · Job summary: · • The Customer Solution Center Appeals and Grievances (A&G) Nurse Sp ...
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Nursing specialist
1 week ago
Aurora Ventures Arcadia, United StatesArcadia Care Professional (m/f/d) · Full-time or part-time · Herzlia-Allee, 45770 Marl, Germany · With or without professional experience · Do you want to work for the largest nursing home operator in Germany? · Are you looking for a crisis-proof employer? · If you answered "yes" ...
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Kaiser Los Angeles, United StatesJob Summary: Sign On Bonus 10% of annual salary offered to eligible external hires. · The Clinical Nurse Specialist role at Kaiser Permanente Southern California Region is a clinical manager who partners with the operational manager to ensure that nursing staff delivers safe an ...
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Nursing specialist
1 week ago
Spectrum Dynamics Pomona, United StatesPomona Care Professional (m/f/d) · Full-time or part-time · 45721 Haltern am See-Sythen, Germany · With or without professional experience · Do you want to work for the largest nursing home operator in Germany? · Are you looking for a crisis-proof employer? · If you can answer ye ...
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Nursing specialist
1 week ago
Skyline Enterprises Redondo Beach, United StatesNursing Professional (m/f/d) · Full-time or part-time · Rheinlanddamm 2-4, 44139 Dortmund, Germany · With or without professional experience · Are you interested in working for the largest nursing home operator in Germany? · Are you looking for a stable employer? · If you answere ...
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Nursing specialist
1 week ago
Spectrum Dynamics Park, United StatesPark Care Professional (m/f/d) for Frechen · Full-time or part-time · 50126 Bergheim, Germany · With or without professional experience · Do you want to work for the largest nursing home operator in Germany? · Are you looking for a crisis-proof employer? · If you can answer yes t ...
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Nursing specialist
1 week ago
Aurora Ventures Glendora, United StatesOur company's goal is to close gaps in the care and health market in the Black Forest and Lake Constance through new and customer-oriented business areas, and to provide a comprehensive range of services. The focus is on providing home care for senior living communities, offering ...
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Nursing specialist
1 week ago
Eclipse Enterprises La Habra Heights, United States"The door is open - even more so, the heart" · The Reisach Clinics, acute clinics for psychosomatic medicine and psychotherapy, are a privately owned family business with two locations in the La Habra Heights region. We offer you a workplace where not only your professional compe ...
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quality management nurse specialist rn ii
4 weeks ago
L.A. Care Health Plan Los Angeles AFB, CA , USA, United StatesSalary Range: $88, Min.) - $115, Mid.) - $142, 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 operate ...
utilization management/appeals and grievances nurse specialist rn ii - LOS ANGLS AFB, CA , USA, United States - L.A. Care Health Plan
Description
Salary Range:
$88, Min.) - $115, Mid.) - $142, 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 in five health plans, we make sure our members get the right care at the right place at the right time.
Mission:
L.A.
Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with L.A.
Duties
Conducts intake/triage and appropriate classification of Clinical A&G, and Pharmacy requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department.
Investigation, and resolution of clinical Provider Complaints/ Provider Data Resolution (PDR) (grievances/appeals) utilizing regulatory and internal guidelines and Service Level Agreement (SLA).
Identification of Expedited Cases and resolution within 72 hours.Works with the external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
Investigation and preparation of State Fair Hearing cases as assigned. Prepares resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE).
Conducts reviews and presents to physicians, provider disputes which would be based on medical necessity reviews. Prepares authorizations, after approval by the Medical Director.
Perform other duties as assigned.
Duties Continued
Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience
Required:
At least 5-7 years of experience in Clinical Nursing and 2 years in Medicare/ Medicaid in a managed care/ health plan environment.
Skills
Required:
Excellent interpersonal and communication skills.
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 departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.
Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
Nearest Major Market:
Los Angeles
Job Segment:
Nursing, Registered Nurse, Medicare, Medicaid, Pharmacy, Healthcare