Grievance & Appeals Nurse Specialist - Temp - Orange - Sunshine Enterprise Inc

    Sunshine Enterprise Inc
    Sunshine Enterprise Inc Orange

    22 hours ago

    Default job background
    Description

    Grievance & Appeals Nurse Specialist


    At Sunshine Enterprise USA, we're a community of dedicated professionals committed to excellence and innovation. We take pride in bringing together great people and organizations by fostering a work environment that values creativity, diversity, and growth.


    Job Summary:

    The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews for all lines of business. They ensure appeals and state hearing requests are processed according to regulations, compliance standards, and policies. The incumbent investigates and prepares case narratives and statements of position based on clinical information, benefits, and applicable regulations.


    Position Responsibilities:

    • Participates in a mission-driven culture with a focus on customer service, consistency, dignity, and accountability.
    • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities.
    • Prepares clinical reviews based on clinical guidelines and monitors cases involving medical decisions and quality of care or service decisions.
    • Ensures all cases are completed according to state and federal regulatory requirements, including timelines.
    • Presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
    • Resolves complex and sensitive member issues within established timelines.
    • Maintains departmental database and records by accurately entering case actions.
    • Analyzes and reports cases through GARS' subcommittee.
    • Participates in departmental meetings, trainings, and audits as requested.
    • Oversees state hearing cases.
    • Assists with notification process to members or providers on clinical decisions issued.
    • Discusses appeal process, medical decisions, and hearing rights with members.
    • Assigns position statements and represents the client at state hearings.

    Possesses the Ability To:

    • Analyze and complete written summaries on clinical cases.
    • Conduct research on standards of practice, regulations, and policies relevant to reviewing cases.
    • Communicate issues clearly and timely to members, providers, involved departments, or health networks.
    • Organize and manage activities related to processing cases within the department.
    • Establish and maintain effective working relationships with leadership and staff.
    • Communicate clearly and concisely, both orally and in writing.
    • Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems.

    Experience & Education:

    • High School diploma required.
    • Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.
    • 5 years of healthcare/managed care experience required, preferably in Grievances and Appeals, Utilization Management, and/or Quality Management.

    Preferred Qualifications:

    • Active Registered Nurse (RN) license to practice in the state of California.
    • Bilingual in English and one of the defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

    Knowledge of:

    • Medicare and Medi-Cal healthcare program regulations.
    • Clinical review processes, including analyzing and researching clinical issues.
    • Managed care and healthcare industries.
    • Appeals and grievance processes.

    We believe our employees are the heartbeat of our organization and offer the following benefits:

    • Competitive pay & weekly paychecks
    • Health, dental, vision, and life insurance
    • 401(k) savings plan
    • Awards and recognition programs

    Sunshine Enterprise USA is an Equal Opportunity Employer-Minorities, Females, Veterans, and Disabled Persons

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