Grievance & Appeals Nurse

🔥 12 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $63.9k - $83.1k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 1%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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IEHP

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1995

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 Grant on 2021-02

Insurance • Consulting • Logistics

IEHP is a health plan dedicated to serving low-income individuals and families in Riverside and San Bernardino counties. They offer a variety of programs including Medi-Cal, DualChoice, and Covered California, providing healthcare coverage for residents who may not otherwise have access to necessary medical services. With a focus on holistic health and community wellness, IEHP partners with local doctors and facilities to ensure comprehensive care for their members, supporting them with resources in mental health, fitness classes, and wellness education.

📋 Description

• Work directly with IPAs, hospitals, internal IEHP departments, and the grievance team • Ensure grievance and appeal cases are processed according to Grievance Policy & Procedures and DMHC, DHCS, CMS, and NCQA requirements • Coordinate Member care with the Member’s PCP, IPA, and IEHP team members to provide continuous quality care • Assist in developing quality initiatives • Serve as a resource for IEHP personnel, external practitioners, and providers • Triage and assign grievance and appeal cases when designated • Ensure case timeliness and regulatory requirements are met • Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

🎯 Requirements

• Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting • Experience in an HMO or experience in managed care setting preferred • High school diploma or GED required • Associate’s degree from an accredited institution preferred • Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required • Must have a valid California Driver's License • Working knowledge and understanding of Member and Provider legal rights to access the grievance and appeals resolution process • Knowledge of DHCS, DMHC, CMS, IEHP, and NCQA requirements and regulatory guidelines • Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS • Proficiency with spreadsheet, database, and word processing applications • Excellent written and verbal communication skills • Critical thinking and strong problem-solving capability • Commitment to incorporating LEAN principles into daily work • Strong attention to detail • Ability to prioritize work and adhere to project deadlines • Ability to escalate issues following established protocols • Ability to work in a team setting

🏖️ Benefits

• Competitive salary • 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

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