Job description

Grievance and Appeals Nurse

Contra Costa Health Plan, Martinez, CA

Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate recommendations involving grievance and appeal determinations.

Per diem position. 20 hours/week, weekdays in an office setting.

Requirements:

• 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background
• Current active unrestricted RN license to practice as a health professional within the scope of licensure in California
• Excellent written and oral communication skills
• Proficiency with PC-based software programs including Word, Excel, and Outlook
• Strong critical thinking, analytical, research and organizational skills
• Knowledge of and experience with Utilization Management regulations, requirements, and clinical guidelines
• Experience with grievances and appeals required

Position Functions and Responsibilities:

• Conducts investigations and reviews of member grievances, provider and member appeals, and Potential Quality Issues
• Extrapolates and summarizes medical information for medical director or consultants
• Ensures that appeals and grievances are resolved timely to meet regulatory time-frames
• Documents and logs appeal/grievance information on relevant tracking systems
• Generates written correspondence to providers, members, and delivery systems
• Recognize and identify potential quality care concerns
• Act as member advocate addressing member concerns
• Maintains current knowledge of CMS, DHCS, and NCQA regulations and standards relating to grievances and appeals
• Participate in audits and related activities as required

Job Types: Part-time, Per diem, Temporary

Pay: $149,721.72 - $186,981.84 per year

Benefits:

• Flexible schedule

Standard shift:

• Day shift

Supplemental schedule:

• Overtime

Weekly schedule:

• Monday to Friday
• Weekend availability

Experience:

• Healthcare Grievance and Appeal: 2 years (Required)

License/Certification:

• BLS Certification (Required)
• RN license in CA (Required)

Work Location: One location

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