Lead Customer Solution Center Appeals and Grievances RN

Job Description

The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit.This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all line of business (LOB).

The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines.Leads and works closely with assigned team daily.

This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.

Qualifications

Required:

• At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting,
• At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment.
• At least 1 year of leading a process, program, or staff experience.

Preferred:

• Clinical acute experience.

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.