-
Nursing specialist
3 weeks 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 ...
-
QI Nurse Specialist
2 weeks ago
CalOptima Orange, United States· QI Nurse Specialist (RN) (Utilization Management) · CalOptima · CalOptima Health is seeking a highly motivated an experienced QI Nurse Specialist (RN) (Utilization Management) to join our team. The Quality Improvement (QI) Nurse Specialist for Utilization Management (UM) ...
-
Grievance and Appeals Nurse Specialist
1 week ago
Impresiv Health Orange, United StatesTitle: Grievance and Appeals Nurse Specialist · Duration: up to 6 months · Compensation: $40.87-$67.82 · **In Office** · Description: · The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, in ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks ago
Crimson Solutions Fairview, United StatesWe are looking for a nursing professional (m/f/d) for Fairview House at Brühlpark in Schrozberg, in full-time, part-time, or mini-job employment. There are few professions that are as meaningful, fulfilling, and challenging at the same time. Although not everyone may see it this ...
-
Nursing specialist as residential area manager
3 weeks ago
Omega Innovations Garden Grove, United StatesAre you passionate about helping people in your nursing profession and value joy in your work? · ▸ If respectful interaction in the workplace is important to you · ▸ If you are looking for a strong team and a good working atmosphere · ▸ If appreciation and recognition motivate yo ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks 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 ...
-
Nursing specialist
3 weeks 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 ...
-
TEMP - Grievance & Appeals Nurse Specialist
2 weeks ago
Cogent Infotech Corp Orange, United StatesJob Description : · The client is seeking a highly motivated an experienced TEMP - Grievance & Appeals Nurse Specialist to join the team. The Grievance and Appeals Nurse Specialist participates in managing the client's medical appeals and state hearing reviews for all lines of b ...
-
Nursing specialist
3 weeks 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" ...
-
TEMP - Grievance & Appeals Nurse Specialist
1 week ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together." — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and profession ...
-
TEMP - Grievance & Appeals Nurse Specialist
2 weeks ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and profession ...
-
TEMP - Grievance & Appeals Nurse Specialist
1 week ago
Equiliem Orange, United StatesHealth is the single largest health plan in Orange County, serving one in four residents. Our motto "Better. Together. is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals w ...
-
Nursing Program Specialist
4 weeks ago
Healthy Start Coalition of Orange County Orange County, United StatesJob Description · Job DescriptionJob Title · Nursing Program Specialist - NFP · Work Location · HYBRID: Orlando - Coalition Office and Community (Partner and/or Physician) · Division/Department · Healthy Start · Supervisor · Nurse Family Partnership - Nurse Consultant · Employmen ...
-
Nursing specialist/geriatric nurse
3 weeks ago
Omega Enterprises Alondra Park, United StatesAre you passionate about helping people in your nursing profession and value joy in your work? · ▸ If respectful interaction in the workplace is important to you · ▸ If you are looking for a strong team and a good working atmosphere · ▸ If appreciation and recognition motivate ...
-
Nursing specialist as residential area manager
3 weeks ago
Apex Innovations Silverado, United StatesDo you love being able to help people in your nursing profession and value the joy of work? · ▸ If respectful interaction in the workplace is important to you · ▸ If you are looking for a strong team and a good working atmosphere · ▸ If appreciation and recognition motivate you · ...
Grievance and Appeals Nurse Specialist - Orange, United States - Impresiv Health
Description
Title:
Grievance and Appeals Nurse Specialist
Duration:
up to 6 months
Compensation:
$40.87-$67.82
In Office
Description:
The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.
The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures.
The incumbent will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions.
The incumbent will clearly articulate the facts and disputes to the Administrative Law Judge hearing the case. The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.What You Will Do:
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
Presents recommendations based on clinical review, criteria and organizational policies to client's physician reviewers for final determination.
Resolves complex and sensitive member issues within established timelines.
Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
Analyzes and reports cases through GARS' subcommittee.
Oversees state hearing cases.
Discusses appeal process, medical decisions and hearing rights with members.
Assists members in coordinating their services with providers and communicates the status and outcome to members.
Assigns position statements and represents client at state hearings.
Participates in departmental meetings, trainings and audits as requested.
Assists with the notification process to members or providers on the clinical decision issued.
Completes other projects and duties as assigned.
You Will Be Successful If:
Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e
g, Microsoft Office:
Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Ability to visually read information from computer screens, forms and other printed materials and information.
Ability to speak (enunciate) clearly in conversation and general communication.
Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
Lifting and moving objects, patients and/or equipment 10 to 25 pounds
What You Will Bring:
High school diploma required.
Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.
5 years of health care/managed care experience required.
Preferably in the following related areas of responsibility:
Grievances and Appeals, Utilization Management, and/or Quality Management.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Bilingual in English and one of the following languages preferred: Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do
provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv
