Grievance & Appeals Nurse

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Responsibilities

• Work directly with IPAs, Hospitals, internal IEHP departments, and the grievance team to ensure grievance and appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA.
• Care for Members in conjunction with the Member’s PCP and IPA and/or IEHP Team Members to provide continuous quality care and assist in the development of quality initiatives.
• Serve as a resource person to IEHP personnel, as well as external practitioners and Providers. When designated, triage and assign grievance and appeals cases to ensure timeliness and regulatory requirements are met.

Commitment to Quality

• The IEHP Team is committed to incorporating IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

• Competitive salary
• CalPERS retirement
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Paid life insurance for employees
• Pet care insurance

Education & Requirements

• Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting- Experience in an HMO or experience in managed care setting preferred
• High school diploma or GED required
• Associate’s degree from an accredited institution preferred
• Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required

Key Qualifications

• Valid California Driver’s License preferred
• Working knowledge and understanding of:
• Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS and IEHP
• Outside agencies and resources such as CCS, CMS, DMHC, or DHCS
• Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA
• Microcomputer applications: spreadsheet, database, and word processing
• Excellent written and verbal communication skills
• Proven ability to:
• Demonstrate critical thinking and strong problem-solving capability
• Demonstrate a commitment to incorporating LEAN principles into daily work
• Possess strong attention to detail
• Prioritize work to ensure adherence to project deadlines
• Effectively escalate issues as identified, following established protocols
• Maintain a positive attitude and ability to work in a team setting

Pay Range

• $63,897.60 USD Annually - $83,075.20 USD Annually