Grievance and Appeals Nurse (LVN)

About the position

The Grievance and Appeals Nurse (LVN) at Kinetic Personnel Group is responsible for managing grievance cases within a public health plan. This role involves coordinating care with various stakeholders, ensuring compliance with regulatory guidelines, and serving as a resource for both internal and external parties. The position operates in a hybrid work environment, allowing for both remote and in-office work, and focuses on maintaining high standards of care and quality initiatives.

Responsibilities
• Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
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• Understand Member and Provider legal rights to access grievance resolution process.
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• Ensure compliance with state and federal guidelines including CMS requirements.
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• Work closely with the Grievance & Appeals Team to investigate and coordinate care for Member grievances and appeals.
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• Triage new cases to identify medical urgency and notify Immediate Needs team for timely resolution.
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• Complete Quality Assurance Reviews on all new Grievance & Appeal cases.
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• Audit daily reports to assure all Grievance & Appeal cases are captured and opened within regulatory timeframes.
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• Assign new Grievance & Appeal cases to appropriate team for investigation and resolution.
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• Comply with mandated reporting obligations for allegations of abuse.
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• Review case coding for accuracy and assist in resolution of Member medical issues.
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• Identify case issues and assist in developing quality initiatives.
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• Prepare recommendations to uphold or deny appeals for Medical Director approval.
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• Prepare files for Appeals Committee reviews.
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• Serve as subject matter expert for appeals and assist clinical and non-clinical Team Members.
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• Notify Grievance & Appeals Management of trends related to contracted practitioners.
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• Conduct initial medical review and clinical oversight of received team cases.
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• Support protocols and goals of department and organization.

Requirements
• Possession of a high school diploma or equivalent.
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• Active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN.
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• Two (2) years or more case management or utilization management experience in a managed care setting.
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• Knowledge of outside agencies and resources such as CCS, CMS, DMHC.
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• Valid California Driver's License.

Nice-to-haves
• Experience in Grievance & Appeals (2 years preferred).
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• Experience in Utilization management (2 years required).

Benefits
• Health insurance
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• Dental insurance
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• Vision insurance

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