Grievance and Appeals Nurse Specialist

Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance and
appeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of cases
to ensure members receive high quality healthcare services. Working closely with PHC Medical
Directors, oversees assessments for medically necessary determinations, quality of care
concerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadership
to Grievance & Appeals Case Analysts to ensure clinical solution followed on casework.
Ensures casework complies with DHCS guidelines, NCQA standards, and PHC best practices.
Works independently, prioritizes case deliverables, remains customer-focused and stays current
on changes in the healthcare system that may trigger member dissatisfaction. This position is
eligible for teleworking.

• Assesses all cases to determine if members have any emergent or immediate
  medical needs. Identifies potential quality of care, fraud, waste, and abuse issues.
  Takes appropriate actions.
• Executes independent clinical judgement in assessing members concern, care and
  treatment. Evaluates and solves for any deviations in the standard of care,
  regulations, policy and procedures relevant to assigned cases.
• Conducts comprehensive clinical assessments as they relate to a member’s
  physical, psychosocial, environmental, safety, developmental, cultural and linguistic
  needs. Takes appropriate actions.
• In coordination with the Grievance & Appeal Case Analyst, may contact members as
  it directly relates to their immediate clinical concerns. May refer to Care Coordination
  for continued/ongoing case management.
• Assesses and formally classifies disputed benefits according to NCQA pre-service
  and post-service classifications.
• Provides guidance to determine if/which medical records are needed to thoroughly
  evaluate the substance of on grievance and appeal cases.
• Evaluates all received medical records and writes clinical summary of observations
  in preparation of MD Director’s review. Medical records average 30-500 pages per
  case.
• Works closely with Grievance & Appeal Case Analyst, ensuring clinical content of
  resolution letters reflect clinical accuracy and medical terms are written in layman
  language
• Responsible for end-to-end investigation of exempt grievances. Works closely with
  PHC Medical Directors to identify and address concerns related to quality of care,
  HIPAA violations, fraud, waste, or abuse activity.
• Documents all casework activity thoroughly, accurately, timely, and ethically.
• Manages assigned cases so they are completed within DHCS timeframes, according
  to G&A Desktop procedures, and/or as directed by management.
• Serves as a clinical resource to the Grievance & Appeals team
• Identifies systematic or recurring issues that create barriers to high quality healthcare
  and reports them to leadership.
• Can work in a team environment
• Effective communicator in all modes of communication (e.g., written, verbal)
• May serve as a backup to absent Grievance & Appeals Nurse Specialists
• Attends meetings as needed including but not limited to Clinical Case Forum meetings,
  Department Meetings, and Division Meetings
• Maintains a Registered Nurse licensure in good standing
• Other duties as assigned.

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

HIRING RANGE:

$ 91,163.24 - $ 118,514.23

IMPORTANT DISCLAIMER NOTICE

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 or definitive 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.