Grievance & Appeals Nurse, RN; Remote

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Grievance & Appeals, the Grievance & Appeals Nurse, RN (G&A Nurse, RN) is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the Grievance team to ensure Grievance and Appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA.

This position coordinates care, within the scope of their licensure, of members in conjunction with the member’s PCP and IPA and/ or IEHP Team Members to provide continuous Quality-Of-Care and assist in the development of quality initiatives. The incumbent serves as a resource person to IEHP personnel, as well as external practitioners and providers. When designated, the G&A Nurse, RN will also be responsible for triaging and assigning Grievance and Appeals cases to ensure timeliness and regulatory requirements are met.

The G&A Nurse, RN will support appropriate Grievance case categorization inclusive of Quality of Care, identification of member harm, in addition to the completion of required reporting to internal departments (e.g. Critical Incidents and Potential Quality Incidents) and external mandatory reporting (e.g. CPS and APS). Commitment to Quality:
The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

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

• 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
  • Patient rights and ethical decision-making frameworks
  • Medical necessity and level of care, chronic disease and complex clinical cases
  • Diagnostic and procedural understanding in a clinical setting
  • Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA
  • Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS, and/or IEHP
• Microcomputer applications: spreadsheet, database, and word processing;
  Excellent interpersonal and communication skills
• Time management and priority setting skills
• Proven ability to:
  • Demonstrate a commitment to incorporate LEAN principles into daily work
  • Work effectively with various internal departments and external Providers and entities
  • Assess complex Grievance & Appeal cases and recommend appropriate action
  • Analyze documentation of incoming cases to determine appropriateness of care…