Lead Customer Solution Center Appeals and Grievances RN

Job Summary

The Lead 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 involves reviewing and processing complex and/or escalated clinical A&G cases, analyzing medical records and insurance policies, and ensuring compliance with regulatory guidelines.

Duties

• Review and process complex and/or escalated clinical A&G cases.
• Analyze patient medical records, clinical documentation, and insurance policies to determine medical necessity.
• Prepare and review A&G files for submission to providers and internal departments.
• Work with other departments to ensure all aspects of a case are appropriately managed.
• Conduct targeted and random clinical case audits to ensure regulatory and departmental guidelines are met.
• Assist Clinical Supervisors in identifying deviations in performance and implementing process changes to improve performance.
• Provide accurate and timely written statistical reports to aid in compliance status evaluation.
• Ensure all clinical A&G cases are processed accurately and within established timelines.
• Maintain documentation of all communications in the A&G system to ensure thorough tracking of case status.
• Lead the work of assigned staff; regularly assigns and checks their work, providing guidance, training, and feedback.
• Communicate, resolve conflicts, and motivate staff in a collaborative environment.
• Adjust to changing circumstances within the team and handle escalations as required.

Education & Experience

• Education: Not specified
• Experience:
  • 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.

Skills

• Extensive knowledge of healthcare regulations and managed care guidelines.
• Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity.
• Communication, conflict resolution, and motivational skills.
• Ability to work independently and collaboratively with a team.
• Ability to adjust to changing circumstances within the team.
• Good verbal and written communication skills.

Physical Requirements

• Work after hours, on weekends, holidays, a hybrid remote schedule, and occasional flexibility in hours/shift in critical situations and work on-call.
• Handle various caseloads and adapt to changing priorities.

Additional Information

• This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include redistributed work assignments, team projects, and other priorities as assigned.
• L.A. Care offers a wide range of benefits including Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental, and Vision, Wellness Program, and Volunteer Time Off (VTO).