Grievance & Appeals Nurse, RN

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $91.2k - $120.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 5%

What it means: how likely this posting is sitting open without active hiring.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 to process Grievance and Appeal cases according to policy, procedures, and regulatory requirements • Coordinate member care within the scope of licensure with the member’s PCP, IPA, and/or IEHP Team Members • Provide continuous quality-of-care support and assist in developing quality initiatives • Serve as a resource for IEHP personnel, external practitioners, and providers • Triage and assign Grievance and Appeals cases when designated, ensuring timeliness and regulatory compliance • Support appropriate Grievance case categorization, including Quality of Care and member-harm identification • Complete required internal reporting, including Critical Incidents and Potential Quality Incidents • Complete mandatory external reporting, including CPS and APS • Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

🎯 Requirements

• Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting required • Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting required • Associate's Degree in Nursing from an accredited institution required • Bachelor's Degree in Nursing from an accredited institution preferred • Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required • Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS • Knowledge of patient rights and ethical decision-making frameworks • Knowledge of medical necessity and level of care, chronic disease and complex clinical cases • Diagnostic and procedural understanding in a clinical setting • Knowledge of regulatory guidelines surrounding grievances and appeals per CMS, DHHS, DMHC and NCQA • Knowledge of member and provider legal rights to access the grievance and appeals resolution process • Microcomputer applications: spreadsheet, database, and word processing • Excellent interpersonal and communication skills • Time management and priority setting skills • Ability to incorporate LEAN principles into daily work • Ability to work effectively with internal departments and external providers and entities • Ability to assess complex Grievance & Appeal cases and recommend appropriate action • Ability to analyze documentation of incoming cases • Ability to effectively escalate issues following established protocols • Word processing and data entry involving computer keyboard and screens • Automobile travel within the Inland Empire • Ability to occasionally lift or move up to 25 pounds • Required vision abilities including close, distance, color, peripheral and depth perception, and ability to adjust focus

🏖️ Benefits

• Competitive salary • CalPERS retirement • 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 • 457(b) option with a contribution match • Paid life insurance for employees • Pet care insurance