Appeals & Grievances Nurse

Summary Description:

The Appeals & Grievances Nurse requires the abilities and knowledge of a California-licensed Registered Nurse (RN). Specifically, the Appeals & Grievances Nurse reports directly to Western Health Advantage’s (WHA’s) Utilization Operations Director and reviews appeal and grievance cases requiring clinical evaluation. This position works closely with WHA’s Appeals & Grievances Supervisor and staff, Medical Director, Chief Medical Officer, and Clinical Pharmacists to ensure that Utilization Management (UM) review functions are carried out effectively at the corporate health plan level. This position works consistently work with the Appeals & Grievances Department to provide clinical evaluation, problem solving, and direction on appeal and   grievance cases, to include completion of case summaries for presentation to the Appeal Review Meeting. Additionally, this position assists the Senior Appeals & Grievances Nurse with review of written response to requests that come from the CA Department of Managed Health Care (DMHC) and with expedited requests, to include appeals regarding discharge or transfer of a Plan member.

Representative Duties:

• Review all appeal/grievance requests involving medical necessity or that require clinical evaluation, and coordinate with all entities involved within the provision of contracts and delegation agreement between the Contracted Medical Groups and Hospital Systems.

• Perform research, evaluation and case preparation of complex appeal & grievance requests involving new technology and experimental treatments.

• Evaluate appeal cases to determine clinical urgency and provide direction to Appeals & Grievances staff.

• Work with our Medical Groups regarding post, concurrent, and retrospective review of member appeals when involving admissions/discharges through hospitals, skilled nursing facilities, and acute rehabilitation units, to include referrals to care management for assistance, and coordinates services with Medical Group review staff, as needed (i.e., works with hospital discharge planners and Medical Group nurses to ensure smooth transfers, appropriate discharges, in- network follow-up care/services, etc.).

• Maintain effective and routine interaction with representatives from contracted IPAs/Medical Groups to ensure timely access to care, assist with benefit interpretation, treatment for Plan members, coordination of care, and that all UM letters align with WHA’s standards, upon appeal review.

• Interface and collaborate with departmental team members, as well as other functional area leaders, on special projects and/or towards the accomplishment of company-wide business goals, objectives and project deliverables.

• Provide direction and coordination to the Appeals & Grievances Department regarding Commercial and Medicare appeals and grievances cases.

• Draft resolution letters for Medical Directors with regarding to appeal cases that are upheld for medical necessity. This includes utilization of member plan guidelines, copayment summaries, or the Evidence of Coverage.

• Assist Utilization Operations Director in the development and provision of educational materials and information for WHA staff and delegated IPA/Groups related to Plan benefits and UM/CM, as well as A&G, processes.

• Assist in maintaining a current quick reference guide for review staff by updating WHA’s Prior Authorization and DME Benefit Matrix.

• Participate with the Appeals & Grievances team in the implementation, review, and analysis of studies and audits, with special attention to technical assistance guide and technical specifications for performance measurement activities.

• Participate in Appeals & Grievances readiness for regulatory agency audits, accreditation surveys, responds to request for proposals (RFP), with preparation of reports, documents, and binders.

• Participate in conference calls with the CA DMHC attorneys and their senior council regarding appeal/grievance cases, to include submission of information for an Independent Medical Review.

• Provide clinical support for evaluation, problem solving and direction to Clinical Resources Nurses and Appeals & Grievances staff on processing, research, and resolution of appeal and grievance cases.

• Provide clinical support for sales, marketing and wellness department activities as needed – including developing or reviewing written materials, presentations and or activities.

• Coordinate with Appeals & Grievances and Quality Management staff to ensure screening of cases identified as possible Potential Quality Issues.

• Assist with escalation of evaluation review for utilization of non-network emergency/urgent hospital admissions and transfers and provide support to the CRN to facilitate the provision of appropriate services through effective collaboration with all stakeholders. It is important to note that routine utilization and case management functions are delegated by WHA to its contracted IPAs, Medical Groups and other carve-out entities.

• Thoroughly research, review, and prepare cases for Medical Director review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters, etc. (e.g., OOA second opinions, organ transplants, cancer clinical trials, new technology/experimental determinations, etc.).

• Assist Member Service Representatives and IPA/Medical Group Utilization Management staff with interpretation of benefits, eligibility requirements and regulatory compliance issues regarding UM & A&G processes for Commercial and Medicare members.

• Initiate and follow up on members identified for referral for Case Management, Disease Management and/or Behavioral Health services.

• Provide care coordination, education and support for members undergoing transgender surgery services.

• Assist with DMHC & CMS regulatory and NCQA accreditation audits.

• Perform other duties and special projects as assigned.

Qualifications:

• Bachelor’s Degree in Nursing.

• 3 years’ experience in utilization/case management, discharge planning and/or appeals & grievances in a managed    care environment, with increased responsibilities.

• Valid Registered Nurse (RN) License is required prior to employment and must be maintained for the duration of employment.

• Utilization Management, Quality Management, or CCM certification a plus but not required.

• Experience with California Code of Regulation with the CA Department of Managed Healthcare, regulations with the Centers for Medicare & Medicaid Services (CMS), as well as the technical specification requirements under the National Committee for Quality Assurance (NCQA) accreditation.

• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, the ability to create formulas and graphs in Excel and import them into Word documents.

Must be able to speak, read, write, and understand the primary language(s) used in the workplace.

Salary:

$85,000.00 – $115,000.00 Annually

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.