Offer summary

Qualifications:

Bachelor’s degree in Nursing required., 3-5 years of experience, including 1 year in case management and 1 year in an acute care setting., Current California Registered Nurse license is mandatory., Knowledge of PHC Grievance & Appeals processes and managed care preferred..

Key responsabilities:

Assess and determine members' emergent medical needs and quality of care issues.

Conduct comprehensive clinical assessments and document casework activity accurately and timely.

Collaborate with Grievance & Appeal Case Analysts to address clinical concerns and ensure compliance with guidelines.

Identify and report systematic issues affecting healthcare quality to leadership.

Job description

Overview:

Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance and
appeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of cases
to ensure members receive high quality healthcare services. Working closely with PHC Medical
Directors, oversees assessments for medically necessary determinations, quality of care
concerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadership
to Grievance & Appeals Case Analysts to ensure clinical solution followed on casework.
Ensures casework complies with DHCS guidelines, NCQA standards, and PHC best practices.
Works independently, prioritizes case deliverables, remains customer-focused and stays current
on changes in the healthcare system that may trigger member dissatisfaction. This position is
eligible for teleworking.

Responsibilities:

Assesses all cases to determine if members have any emergent or immediate
medical needs. Identifies potential quality of care, fraud, waste, and abuse issues.
Takes appropriate actions.
Executes independent clinical judgement in assessing members concern, care and
treatment. Evaluates and solves for any deviations in the standard of care,
regulations, policy and procedures relevant to assigned cases.
Conducts comprehensive clinical assessments as they relate to a member’s
physical, psychosocial, environmental, safety, developmental, cultural and linguistic
needs. Takes appropriate actions.
In coordination with the Grievance & Appeal Case Analyst, may contact members as
it directly relates to their immediate clinical concerns. May refer to Care Coordination
for continued/ongoing case management.
Assesses and formally classifies disputed benefits according to NCQA pre-service
and post-service classifications.
Provides guidance to determine if/which medical records are needed to thoroughly
evaluate the substance of on grievance and appeal cases.
Evaluates all received medical records and writes clinical summary of observations
in preparation of MD Director’s review. Medical records average 30-500 pages per
case.
Works closely with Grievance & Appeal Case Analyst, ensuring clinical content of
resolution letters reflect clinical accuracy and medical terms are written in layman
language
Responsible for end-to-end investigation of exempt grievances. Works closely with
PHC Medical Directors to identify and address concerns related to quality of care,
HIPAA violations, fraud, waste, or abuse activity.
Documents all casework activity thoroughly, accurately, timely, and ethically.
Manages assigned cases so they are completed within DHCS timeframes, according
to G&A Desktop procedures, and/or as directed by management.
Serves as a clinical resource to the Grievance & Appeals team
Identifies systematic or recurring issues that create barriers to high quality healthcare
and reports them to leadership.
Can work in a team environment
Effective communicator in all modes of communication (e.g., written, verbal)
May serve as a backup to absent Grievance & Appeals Nurse Specialists
Attends meetings as needed including but not limited to Clinical Case Forum meetings,
Department Meetings, and Division Meetings
Maintains a Registered Nurse licensure in good standing
Other duties as assigned.

Qualifications:

Education and Experience	Bachelor’s degree in Nursing, 3-5 years’ experience to include at least one (1) year of case management experience and one (1) year in an acute care setting; or equivalent combination of education and experience. CCM desired. Knowledge of PHC Grievance & Appeals processes. General knowledge of managed care with emphasis in UM or CM preferred.
Special Skills, Licenses and Certifications	Current California Registered Nurse license. Critical thinker. Organized. Thorough knowledge of utilization and case management programs and related criteria and protocols. Experience in managed care business practices and ability to access data information using computer systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies	Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required. Ability to apply clinical judgment to complex medical situations and make quick decisions in a fast-paced environment. Works well under pressure and maintains a professional composure when interacting with all stakeholders, including members.
Work Environment And Physical Demands	Daily use of telephone and computer for most of the day. Standard cubicle workstation or telecommute eligible. When required, ability to move, carry or lift objects weighing up to 25 lbs.

All HealthPlan employees are expected to:

Provide the highest possible level of service to clients;
Promote teamwork and cooperative effort among employees;
Maintain safe practices; and
Abide by the HealthPlan’s policies and procedures, as they may from time to time be

HIRING RANGE:

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.