• Case Manager, Grievance Clinical Lead

    Job Locations US-CA-Fairfield
    Job ID
  • Overview

    Initiates and coordinates a multidisciplinary team approach to case management and handling of grievances with members, providers, CMO, departmental directors, managers, and others to evaluate, monitor, and assure that medically necessary services are provided in a quality, efficient, and timely manner. This position may be assigned cases requiring case management, disease management, or special initiative programs.


    • Reviews all grievances (complaints and appeals) for clinical components and provides clinical oversight to grievance staff.
    • Provides general clinical support and guidance to all non-clinical members of the grievance department and non-clinical authorized representatives.
    • Provides assistance to members as it directly relates to their immediate concerns and refers to Care Coordination for continued/ongoing case management.
    • Identifies potential quality issues and fraud, waste, and abuse. Initiates investigations to process referral.
    • Initiates and coordinates grievances that require discharge planning and alternative health care services.
    • Ensures development and implementation of a smooth continuum of care via effective, frequent communication with evaluated providers and significant others.
    • Coordinates referrals and authorizations for services required for the improvement of the patient’s health status.
    • Coordinates with Member Services, Claims, health care providers, and Health Services staff to identify members suitable for case management.
    • Coordinates activities and services for PHC members in Disease Management programs, to include education of providers and members on the programs and eligibility requirements. Participates in the annual evaluation of program effectiveness.
    • Assists providers and members with benefit interpretation and applicable limitations as related to Title 22 or Medi-Cal Provider Manual.
    • Notifies Claims department of benefit decisions and CM intervention.
    • Ability to assertively and diplomatically distribute referrals for care.
    • Works with PHC’s Grievance Coordinator to resolve member issues.
    • Reviews responses written by PHC’s Grievance Coordinator for State Hearings or for Medicare review entities.


    • Prepares and/or assists in the preparation of Statement of Position for state hearings or any second level review.
    • As appropriate or needed, acts as a PHC representative at state hearings.
    • Maintains knowledge of the grievance process.
    • Assists grievance staff and prioritizes grievances according to department standards and quality requirements to ensure all state and federal requirements are satisfied.
    • Sends out correspondence to members, providers, and state/federal agencies within regulatory requirements.
    • Prepares for and participates in regulatory site visits.
    • Consults and coordinates with various internal departments, plans, providers, businesses, and government agencies to obtain information and implement operation changes and process improvement.
    • Provides clinical guidance to PHC staff.
    • Participates in special projects and assignments as required.


    Education and Experience

    Bachelor’s degree in Nursing, 3-5 years experience to include at least one (1) year of case management experience and one (1) year in an acute care setting; or equivalent combination of education and experience. CCM desired. Knowledge of PHC Grievance and Appeals processes. General knowledge of managed care with emphasis in UM or CM preferred.


    Special Skills, Licenses and Certifications

    Current California Registered Nurse license. Thorough knowledge of utilization and case management programs and related criteria and protocols. Experience in managed care business practices and ability to access data information using computer systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.


    Performance Based Competencies

    Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required. Ability to understand and ensure compliance with established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply clinical judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.


    Work Environment And Physical Demands

    Daily use of telephone and computer for most of the day. Standard cubicle workstation. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.



    Additional Preferred Skills:  Current RN license.  Experience in managed care business practices and ability to access data information using computers systems.  General knowledge of managed care with emphasis in UM or CM preferred.  Effective telephone and computer data entry skills.



    All HealthPlan employees are expected to:


    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.




    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.


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