Supervisor, Appeals and Grievances Clinical Operations RN

Salary Range

Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.)

About the Role

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Job Summary

The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical operations of the A&G department, and monitoring the A&G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure.

Responsibilities

• Ensures adequate/appropriate distributions of workforce, assignments and time off requests.
• Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.
• Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements.
• Serves as a super-user on electronic programs and systems used by the department.
• Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines.
• Serves as a leader and role model as well as technical and informational resource for staff and peers.
• Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes.
• Serves as a member/resource/liaison to the A&G Operations Team.
• Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.

Requirements

• Education: Associate's Degree in Nursing Education Preferred, Bachelor's Degree in Nursing
• Experience: At least 8 years of RN acute/clinical care experience. At least 2 years in a lead/supervisory experience.
• Preferred: Previous experience in Medicare/ Medicaid in a managed care/ health plan environment.

Skills

• Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality.
• Strong verbal and written communication skills.
• Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.
• Excellent organizational, time management, and interpersonal skills.
• Must be detailed-oriented, energetic, and an enthusiastic team player.
• Must be able to work independently.

Qualifications

• Licenses/Certifications: Required - Registered Nurse (RN) - Active, current and unrestricted California License.
• Preferred - Required Training - Physical Requirements - Light.

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.

L.A. Care Offers a Wide Range Of Benefits Including Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental and Vision, Wellness Program, Volunteer Time Off (VTO).