Registered Nurse (RN) Manager, Appeals and Grievances General Operations (Clinical)

Job Description

The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business.

Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards.

The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business ow…

Qualifications

Education Required

• Bachelor's Degree in Nursing

Experience Required:

• 6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid Health Plan environment and/or public services or public benefits programs. 
• At least 3 years of management level operations leadership experience.

Licenses/Certifications Required

• Registered Nurse (RN) - Active, current and unrestricted California License

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.