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Grievance & Appeals Regulatory Nurse
Job Description:
- Process all incoming DMHC, DHCS and CMS regulatory cases (Consumer Complaints, Independent Medical Reviews, statement of positions, CMS complaints, etc.) and monitoring timeliness of responses for all Plan lines of business.
- Act as a primary contact between IEHP and regulatory agencies in resolving Member grievance and appeals by maintaining positive communication and working closely with IEHP Compliance and Legal Departments in resolving Members’ complaints, grievances, and appeals.
- File Plan Grievances and Appeals / Claim Dispute / request State Fair Hearing process; distinguishing between an inquiry, a Grievance, an Appeal, a Claim Dispute, and a quality-of-care issue and know how to triage, resolve, or refer incoming calls/correspondence to appropriate personnel.
- Work closely with the Grievance and Appeals Team, with Internal Departments, and DMHC/DHCS/CMS to ensure all Member appeals are investigated, and care is coordinated appropriately.
- Process Plan level appeal and grievance cases as a result of a filed regulatory complaint.
- Review Member appeals and/or complaints and make appropriate determination based on documentation presented by appealing agent with references to federal, state, and local regulations as well as IEHP policy and procedures based on line of business in a timely manner.
- Manage all incoming court documents related to State Fair Hearing (SFH) cases, including preparing for scheduled SFH cases, preparation of witness (e.g., Medical Director) and arranging for appearance / telephonic requests of witnesses as well as exhibit gathering.
- Docket hearing notices, contact State / Office of Administrative hearings, establish duties and time frames in connection with each hearing and disseminate information with follow-up as appropriate.
- Support IEHP’s legal department as requested, to include participating in Plan Civil matters.
- Provide testimony on behalf of IEHP and administrative hearing and represent IEHP at hearings (virtual or in-person) when necessary and appropriate.
- Ensure Member appeals are fully investigated, to ensure timely and accurate decisions to either uphold or overturn denial using appropriate criteria hierarchy and work closely with Medical Director for approval.
- Ensure that written correspondence to Providers, Members, and regulatory entities is generated accurately and timely.
- Provide support to IEHP’s Civil Rights Coordinator with affiliated investigations both at the Plan level and for the Office of Civil Rights.
- Responsible for identifying potential cases that are high risk and using critical thinking to escalate to Manager and make appropriate decisions.
- Participate in LEAN initiatives using A3 thinking and LEAN concepts.
- Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
Requirements:
- Three (3) or more years of experience with case management, utilization management in managed care setting or related experience in a health care delivery setting.
- Experience in an HMO or experience in managed care setting required.
- Experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar) required.
- Experience in either State Fair Hearing (SFH) or Appeals or Grievances referred.
- Advanced professional reporting experience within Microsoft Excel preferred.
- Experience preparing professional, data driven narrative reports for all staff levels preferred.
- Legal processing experience preferred.
- High School Diploma or GED required.
- Bachelor’s degree in a Health-related field from an accredited institution preferred.
- Obtain Center for Medicare and Medicaid Services (CMS) Annual Certification within six (6) months of hire.
- Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required.
- Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN preferred.
Benefits:
- Competitive salary.
- Hybrid schedule.
- CalPERS retirement.
- State of the art fitness center on-site.
- Medical Insurance with Dental and Vision.
- Life, short-term, and long-term disability options.
- Career advancement opportunities and professional development.
- Wellness programs that promote a healthy work-life balance.
- Flexible Spending Account – Health Care/Childcare.
- Paid life insurance for employees.
- Pet care insurance.
