RN Appeals & Grievance Nurse Specialist - FT - 886B

Job Description

The Grievance & Appeals Nurse Specialist provides direct assistance to member's with health care access or benefit coordination issues, ensuring that clinical grievances, complaints and complex issues are investigated and resolved to the member's satisfaction in a manner consistent with LA Care, CMS and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care products, FFS Medi-Cal/Medicare, or commercial insurance. 

Qualifications

EDUCATION

Required: Associate's Degree or Bachelor's Degree in RN

LICENSES/CERTIFICATIONS

Required: Registered Nurse (RN); Current and unrestricted CA RN License

EXPERIENCE

At least 5 years of experience in Clinical Nursing and 2 years in Medicare/ MedicAid in a managed care/ health plan environment.

Excellent interpersonal and communication skills. Good working knowledge of regulatory requirements/standards. Computer literacy and adaptability to computer learning. Time management and priority setting skills.

Must be organized and a team player Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. 

Special Instructions

Req. Number: 886B