Customer Solution Center Appeals and Grievances Nurse Specialist LVN II

Job Summary

The Customer Solution Center Appeals and Grievances Nurse Specialist LVN II is primarily responsible for the overall coordination of the Appeals & Grievance (A&G) program for L.A. Care Health Plan members under the direct supervision and management of the A&G Nurse Specialist, RN and/or Medical Director. This position provides assistance to members with health care access and benefit coordination issues, ensuring that clinical grievances and complex issues are investigated and resolved to the member’s satisfaction consistent with L.A. Care Health Plan and regulatory guidelines. Benefit coordination may involve coordinating multiple L.A. Care Health Plan Lines of Business.

Duties

Work with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.

Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.

Investigate Provider Disputes/PDR and prepares clinical summary for Medical Director determination.

Work with the external providers and Participating Physician Group (PPGs) representatives to obtain relevant medical records and communication documentation.

Investigation and preparation of State Fair Hearing cases as assigned.

Prepare complaint files for Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DMHC), and external review organization (QIO or IRE).  Process the case thru to effectuation and final case documentation in the A&G system of record.

Work with Utilization Management and PNO to facilitate completion of resolution determination.

Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.

Duties Continued

Outreach to providers, vendors, hospitals, and members to request necessary information or to provide case status and/or next steps as needed.  In instances where necessary, send written notifications to appropriate parties. All interactions including verbal outreach and written communication will be documented in the A&G system of record.

Participates inter-rater reliability training and assessments. 

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:
At least 4 years of clinical nurse and managed care experience.

Skills

Required:
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 business units, Plan Partners, participating provider groups, and external agencies.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Required:
License Vocational Nursing (LVN)

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned