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(Archived) Grievances & Appeals Nurse Specialist Needed in Orange, CA
Last Updated: 7/11/22
Job Description
Grievances & Appeals nurse specialist needed in Orange, CA!
Position Responsibilities
- Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
- Presents recommendations based on clinical review, criteria and organizational policies to Client’s physician reviewers for final determination.
- Analyzes and reports cases through GARS’ subcommittee.
- Participates in departmental meetings, trainings and audits as requested.
- Oversees state hearing cases.
- Assists with the notification process to members or providers on the clinical decision issued.
- Discuss appeal process, medical decisions and hearing rights with members.
- Prepares position statements and represents Client at State Hearings.
Experience & Education
- LVN license to practice in the State of California required
- 5 years of health care experience required; preferably in a managed care environment in related area of responsibility.
Knowledge of:
- Medicare and Medi-Cal health care program regulations.
- Clinical review processes including how to analyze and research clinical issues.
- Managed care industry, health care, appeals and grievance processes.
Company Details
Wayne, Pennsylvania, United States
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