Customer Solution Center Appeals and Grievances Nurse Specialist RN II

Company: L.A. Care Health Plan
Location: Los Angeles
Posted on: February 1, 2025

Job Description:

Customer Solution Center Appeals and Grievances Nurse Specialist RN IIJob Category: ClinicalLocation: Los Angeles, CA, US, 90017Position Type: Full TimeRequisition ID: 11547Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan, serving more than 2 million members.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.Job SummaryThe Customer Solution Center Appeals and Grievances (A&G) Nurse Specialist Registered Nurse (RN) II provides direct assistance to members 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.Duties

• Conducts intake/triage and appropriate classification of Clinical A&G and Pharmacy requests, making accurate judgments on appeals, grievances, Provider Claim Disputes, medical records, or other issues.
• Investigates and resolves clinical member complaints (grievances/appeals) utilizing all regulatory requirements.
• Works with external providers and Participating Physician Group's (PPG) representatives to obtain relevant medical records and communication documentation.
• Prepares resolved complaint files for CMS, DMHC, and external review organizations.
• Investigates and prepares State Fair Hearing cases as assigned.
• Conducts reviews and presents provider disputes based on medical necessity reviews.
• Outreaches to providers, vendors, hospitals, and members to request necessary information or provide case status.
• Participates in inter-rater reliability training and assessments.
• Performs other duties as assigned.Education RequiredAssociate's Degree in NursingEducation PreferredBachelor's Degree in NursingExperienceRequired: At least 5 years of experience in Clinical Nursing and 2 years in Medicare/Medicaid in a managed care/health plan environment.SkillsRequired:
• 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.
• Good working knowledge of regulatory requirements/standards.Licenses/Certifications RequiredRegistered Nurse (RN) - Active, current and unrestricted California LicensePhysical RequirementsLightAdditional InformationThis position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.This position requires handling various caseloads and flexibility to adapt to changing priorities.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
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Keywords: L.A. Care Health Plan, Los Angeles , Customer Solution Center Appeals and Grievances Nurse Specialist RN II, Healthcare , Los Angeles, California