Grievance & Appeals Nurse, RN

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

📋 Description

• Collaborate directly with IPAs, hospitals, internal IEHP departments, and the Grievance team to manage Grievance and Appeal cases in accordance with policies, procedures, and regulatory standards.

• Facilitate member care within the framework of licensure in partnership with the member’s PCP, IPA, and/or IEHP Team Members.

• Provide ongoing quality-of-care support and contribute to the development of quality initiatives.

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

• Triage and allocate Grievance and Appeals cases when assigned, ensuring promptness and adherence to regulatory requirements.

• Assist in the accurate categorization of Grievance cases, particularly concerning Quality of Care and identification of member harm.

• Complete necessary internal reporting, which includes Critical Incidents and Potential Quality Incidents.

• Fulfill mandatory external reporting obligations, including to CPS and APS.

• Integrate IEHP Quality Program objectives, such as HEDIS, CAHPS, and NCQA Accreditation.

⛳️ Requirements

• A minimum of two (2) years of experience as an RN in case management, utilization management within a managed care environment, or related experience in a healthcare delivery setting is required.

• At least two (2) years of clinical nursing experience in a hands-on patient care setting is mandatory.

• An Associate's Degree in Nursing from an accredited institution is required.

• A Bachelor's Degree in Nursing from an accredited institution is preferred.

• Must possess an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing.

• Familiarity with external agencies and resources such as CCS, CMS, DMHC, or DHCS is essential.

• Understanding of patient rights and ethical decision-making frameworks is required.

• Knowledge of medical necessity, levels of care, chronic diseases, and complex clinical cases is necessary.

• Proficiency in diagnostic and procedural concepts in a clinical environment.

• Awareness of regulatory guidelines governing grievances and appeals as per CMS, DHHS, DMHC, and NCQA.

• Understanding of legal rights for members and providers regarding access to the grievance and appeals resolution process.

• Proficient in microcomputer applications, including spreadsheets, databases, and word processing.

• Exceptional interpersonal and communication capabilities are essential.

• Strong time management and prioritization skills are required.

• Ability to implement LEAN principles into daily work processes.

• Capacity to collaborate effectively with internal departments and external providers and organizations.

• Skill in assessing complex Grievance & Appeal cases and recommending appropriate actions.

• Competency in analyzing documentation related to incoming cases.

• Ability to escalate issues effectively following established protocols.

• Proficiency in word processing and data entry using computer keyboards and screens.

• Willingness to travel by automobile within the Inland Empire.

• Capability to occasionally lift or move items weighing up to 25 pounds.

• Required vision abilities include close, distance, color, peripheral, depth perception, and the ability to adjust focus.

🏝️ Benefits

• Competitive salary.

• CalPERS retirement plan.

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

• Medical insurance that includes dental and vision coverage.

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

• Opportunities for career advancement and professional development.

• Wellness programs that support a healthy work-life balance.

• Flexible Spending Account for Health Care and Childcare expenses.

• 457(b) plan with a contribution match.

• Paid life insurance for employees.

• Pet care insurance.