Grievance & Appeals Nurse

This is a fully remote position, open to applicants in California.

📋 Description

• Collaborate directly with IPAs, hospitals, internal IEHP departments, and the grievance team.

• Ensure that grievance and appeal cases are managed in accordance with Grievance Policy & Procedures, as well as DMHC, DHCS, CMS, and NCQA standards.

• Coordinate member care with the Member’s PCP, IPA, and IEHP team members to ensure continuous quality care.

• Assist in the development of quality initiatives.

• Act as a resource for IEHP personnel, external practitioners, and providers.

• Triage and assign grievance and appeal cases as needed.

• Ensure compliance with case timeliness and regulatory requirements.

• Integrate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation.

⛳️ Requirements

• A minimum of two (2) years of case management or utilization management experience in a managed care setting, or related experience in a health care delivery environment.

• Preferred experience in an HMO or managed care setting.

• High school diploma or GED is required.

• An Associate’s degree from an accredited institution is preferred.

• Must hold an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians.

• A valid California Driver's License is necessary.

• A working knowledge and understanding of Members' and Providers' legal rights to access the grievance and appeals resolution process.

• Familiarity with DHCS, DMHC, CMS, IEHP, and NCQA requirements and regulatory guidelines.

• Knowledge of external agencies and resources such as CCS, CMS, DMHC, or DHCS.

• Proficiency in spreadsheet, database, and word processing applications.

• Excellent written and verbal communication abilities.

• Strong critical thinking and problem-solving skills.

• A commitment to implementing LEAN principles in daily operations.

• Exceptional attention to detail.

• Ability to prioritize tasks and meet project deadlines.

• Capability to escalate issues as per established protocols.

• Willingness to collaborate effectively in a team environment.

🏝️ Benefits

• Competitive salary.

• On-site state-of-the-art fitness center.

• Medical insurance that includes Dental and Vision coverage.

• Options for life insurance, short-term, and long-term disability.

• Opportunities for career advancement and professional development.

• Wellness programs promoting a healthy work-life balance.

• Flexible Spending Account for Health Care and Childcare.

• CalPERS retirement plan.

• 457(b) option with a contribution match.

• Paid life insurance coverage for employees.

• Pet care insurance available.