Managed Care Nurse Grievance System Coordinator - Remote Position

Managed Care Nurse Grievance System Coordinator – Remote Position

Advanced Health Coordinated Care Organization is hiring a Remote Nurse Grievance System Coordinator. The role supports the operations of the grievance system by preparing clinically informed case files for review by physician-level decision‑makers and managing the intake, investigation, and resolution of member complaints.

Hourly: $34.00 – $50.00 per hour

• Classification: Non‑Exempt
• Status: Part‑time, 28 hours per week (Mon‑Fri, 8am‑5pm PT)
• Salary: $34.00 – $50.00 per hour
• Department: Grievance & Appeals
• Work Location: Remote (local to Oregon)
• Reports To: Chief Compliance & Quality Officer
• Supervision Exercised: Non‑supervisory

The position is responsible for supporting the operations of the Grievance System by preparing clinically informed case files for review by physician-level decision-makers. Responsibilities include gathering and organizing medical records, treatment history, prior authorization data, and applicable clinical guidelines to ensure thorough and timely case preparation, coordinating the intake and resolution of member complaints, and ensuring timely processing of grievances and appeals in compliance with 42 CFR 438, Oregon Health Authority (OHA) contractual obligations, and Section 1557 of the Affordable Care Act (ACA).

• Create and maintain positive relationships between the CCO, its members, and providers.
• Manage the grievance and appeals process from intake to resolution, including triage, investigation, and closure, in compliance with 42 CFR 438.400–438.424 and OHA CCO contract requirements.
• Gather and analyze comprehensive documentation from internal systems (authorizations, claims, care‑coordination notes) and external sources (provider records).
• Clinically contextualize appeal requests by summarizing medical records, treatment timelines, prior authorization and claims decisions, and clinical guidelines for submission to Physician Reviewers.
• Maintain current knowledge of Oregon Health Plan (OHP) benefits, medical‑necessity criteria, covered services, and CCO‑specific clinical programs.
• Develop and maintain grievance and appeal policies and procedures, ensuring OHA approval and regulatory alignment.
• Collaborate with Utilization Management, Customer Service, Claims, and external delegates to ensure consistent application of procedures.
• Use internal tools and systems (claims systems, EHRs, case‑tracking software) to conduct investigations, verify eligibility, manage notification time frames, and confirm plan benefits and authorizations.
• Assist in the preparation and tracking of medical records and member information release forms when needed.
• Apply clinical and critical thinking skills to correctly categorize appeal types, determine review pathways, and ensure appropriate reviewers are engaged.
• Ensure all documentation is complete, accurate, and compliant, including case categorization, authorization adjustments, and timely claims routing.
• Draft, review, and issue member and provider correspondence in accordance with OHA and federal time frames, ensuring language‑access requirements under ACA Section 1557 are met.
• Work independently under time‑sensitive conditions to ensure timely closure of cases in accordance with CCO, OHA, and CMS standards.
• Prepare complete and well‑organized case files for internal audits and administrative hearings.
• Support member and provider education on grievance and appeal rights and procedural steps.
• Maintain professional and objective communication with all stakeholders involved in complaints and appeals.
• Translate complex information related to clinical decisions, benefit denials, and regulatory requirements into clear, accessible language.
• Provide regular case‑trend reports to the Chief Medical Officer and Chief Operating Officer, including clinical insights, escalation themes, and recommendations for quality improvement.
• Uphold strict confidentiality and compliance with HIPAA, CFR, and CCO guidelines in handling PHI and sensitive case data.
• Monitor and report suspected fraud, waste, or abuse per…