Customer solution center appeals and grievances nurse specialist rn ii | Los Angeles, CA

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. Care,

Centers of Medicare and Medicaid Services (CMS) and regulatory guidelines. Benefit coordination may involve coordinating multiple L. A. Care products, Fee for services (FFS )Medi-Cal/Medicare, or commercial insurance.

Duties Conducts intake/triage and appropriate classification of Clinical A&G, and shop 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 member complaints (grievances/appeals) utilizing all regulatory requirements. 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. Work 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. Prepare resolved complaint files for CMS external review organization - Quality Improvement Organization (QIO) or Independent Review Entity (IRE). Conduct reviews and present to physicians, provider disputes which would be based on medical necessity reviews.

Prepare 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. Good working knowledge of regulatory requirements/standards. 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 Paid Time Off (PTO)Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)Nearest Major Market: Los Angeles Job Segment: Nursing, Registered Nurse, Medicare, Medicaid, shop, Healthcare For more details: jobs-search. org/insurance_los-angeles-c426443/customer-solution-center-appeals-and-grievances-nurse-specialist-rn-ii-los-angeles_i1949785548