Grievance LVN 91730 CA
Salary: 27.86 – 27.86
Under the general direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, the Grievance Nurse, LVN is responsible for working directly with the IPAs, Hospitals, internal departments, and the grievance team to ensure grievance 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. Coordinate care of Members in conjunction with the Members PCP and IPA and/ or Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance Nurse, LVN serves as a resource person to personnel, as well as, external practitioners and Providers.
Major Functions (Duties and Responsibilities)
- Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
2. Understand Member and Provider legal rights to access the grievance resolution process, within the respective Provider Organization.
3. Implement management of grievance cases ensuring compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements.
4. Work closely with the grievance team under the direction of the Grievance Nurse Supervisor 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.
5. Grievance Nurse is to review case coding, assist in the resolution of Member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the Members care.
6. Responsible for resolving medical grievances, in conjunction with staff, Grievance Management, and Providers, as applicable.
7. Responsible for identifying case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within grievances and referring to appropriate Team Members.
8. Grievance Nurse shall assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for Members.
9. Responsible for serving as a resource for departments, as well as direct Grievance & Appeals Team Members.
10. Grievance Nurse shall notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified Members. Responsible for initial medical review and clinical oversight of all received team cases.
11. Responsible clinical oversight of assigned Grievance team cases, to include; final nurse review of all non-Quality of Care Grievance cases and thorough investigation of all Quality of Care cases to be reviewed by Medical Director and designated Nurse Reviewer.
12. Ensure all team Grievance cases are processed thoroughly and timely as outlined in compancy policy and procedures and per regulatory guidelines.
13. Ensure all necessary follow up is tasked for completion by designated MedHOK business partners.
14. Generates written correspondence to Providers, Members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation.
15. Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.
16. Demonstrate a commitment to incorporate LEAN principles into daily work.
- Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting.
- Preferred Experience
- Experience in an HMO or experience in managed care setting preferred.
- Education Qualifications
- High school diploma or GED required.
- Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN
- Drivers License Required
- Knowledge of outside agencies and resources such as; CCS, CMS, DMHC, or DHCS. Microcomputer applications: spreadsheet, database, and word processing.
- Skills Requirement
- Excellent written and verbal communication skills.