Grievance & Appeals Nurse, RN (Remote)

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Supervisor, Grievance & Appeals, the Grievance & Appeals Nurse, RN (G&A Nurse, RN) is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the Grievance team to ensure Grievance and Appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA. This position coordinates care, within the scope of their licensure, of members in conjunction with the member’s PCP and IPA and/ or IEHP Team Members to provide continuous Quality-Of-Care and assist in the development of quality initiatives. The incumbent serves as a resource person to IEHP personnel, as well as external practitioners and providers. When designated, the G&A Nurse, RN will also be responsible for triaging and assigning Grievance and Appeals cases to ensure timeliness and regulatory requirements are met. The G&A Nurse, RN will support appropriate Grievance case categorization inclusive of Quality of Care, identification of member harm, in addition to the completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS).

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• 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
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Serve as a subject matter expert for Grievance and Appeals (G&A) and IEHP departments and is a resource for clinical and non-clinical Team Members in expediting the resolution of outstanding issues.
2. Work closely with the Grievance & Appeals Team under the direction of the Grievance Nurse Leadership with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS to ensure all member grievance issues are investigated, and care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures. Directly communicate with IEHP Medical Directors. Resolve medical grievance and appeal cases, in conjunction with IEHP staff, Grievance Management, and Providers, as applicable. Responsible for initial medical review and clinical oversight of all received team cases.
3. Triage new cases to identify medical urgency, Member Harm, appropriate reporting (e.g. APS & CPS) and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution.
4. Review Grievance & Appeal case categorization and classification to ensure it is accurate, assist in the resolution of member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the member’s care.
5. Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities.
6. Identify case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within Grievances and Appeals and referring to appropriate IEHP Team Members.
7. Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for IEHP members.
8. Notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified IEHP members. Work with Team Members to support the protocols and goals of the department and the vision of the organization.
9. Ensure clinical oversight of assigned Grievance and Appeals team cases specific to accurate and appropriate categorization of Quality-of-Care grievance cases and timely identification of Member Harm. Provide direction/guidance to G&A LVNs as it pertains to Quality-of-Care categorization and mis-categorization, Member Harm, Immediate Needs, PQI/Critical incident identification and reporting.
10. Ensure all necessary follow up is tasked for completion by designated MedHOK business partners, to include timely reporting of critical incidents, potential quality incidents and provider preventable conditions
11. Generate written correspondence to Providers, members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation. Prepare files for Grievance and Appeals Committee reviews. Maintain all Grievance & Appeals documentation according to external agency requirements.
12. Audit daily reports to assure all Quality-of-Care grievance and appeal cases are captured and opened within regulatory timeframes, to include the identification of Member Harm.
13. Prepare and finalize administrative appeal cases to include final review decision, appropriate application of review criteria and final resolution to member and requesting Provider.
14. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirements 

• Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting
• Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting
• Experience in an HMO or experience in managed care setting preferred
• Associate’s degree in nursing from an accredited institution required
  • Bachelor’s degree in nursing from an accredited institution preferred
• Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required

Key Qualifications

• Knowledge of:
  • Outside agencies and resources such as CCS, CMS, DMHC, or DHCS
  • Patient rights and ethical decision-making frameworks
  • Medical necessity and level of care, chronic disease and complex clinical cases
  • Diagnostic and procedural understanding in a clinical setting.
  • Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA.
  • Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS, and/or IEHP
• Microcomputer applications: spreadsheet, database, and word processing; Excellent interpersonal and communication skills
• Time management and priority setting skills
• Proven ability to:
  • Demonstrate a commitment to incorporate LEAN principles into daily work
  • Work effectively with various internal departments and external Providers and entities
  • Assess complex Grievance & Appeal cases and recommend appropriate action
  • Analyze documentation of incoming cases to determine appropriateness of care and applicable next steps
  • Effectively escalate issues as identified, following established protocols
  • Maintain a positive attitude and work in a team setting
• Word processing and data entry involving computer keyboard and screens, automobile travel within the Inland Empire
• While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell
• The employee must occasionally lift or move up to 25 pounds
• Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus

Start your journey towards a thriving future with IEHP and apply TODAY!

Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)