DEPARTMENT(S):  Grievance and Appeals Resolution Services (GARS) REPORTS TO:  Manager Clinic Operations, Grievance & Appeals FLSA STATUS:  Non-Exempt SALARY GRADE:  M - $85,000 - $121,000

JOB SUMMARY

The Grievance and Appeals Nurse Specialist participates in managing the organization’s medical appeals and State Hearing reviews for all lines of business; including handling expedited and standard requests.  Ensures appeals and State Hearing requests are processed in accordance with regulations, compliance standards and policy and procedures.  Investigation and preparation of case narratives and Statements of Position based on clinical information, benefits, applicable regulations related to member or provider dispute of decisions.  Clearly articulates the facts and CalOptima’s position regarding dispute to Administrative Law Judge hearing the case.  The incumbent is also responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.

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 CalOptima’s physician reviewers for final determination.
• Resolves complex and sensitive member issues within established timelines.
• Maintains departmental database and records’ integrity by accurately entering case actions to assigned cases.
• 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.
• Assists members in coordinating their services with providers and communicate the status and outcome to members.
• Assigns position statements and represents CalOptima at State Hearings.
• Other projects and duties as assigned.

POSSESSES THE ABILITY TO:

• Communicates clearly and concisely, both verbally and in writing.
• Analyze and complete written summaries on clinical cases.
• Conduct research on standards of practice, regulations and policy and procedures relevant to review cases.
• Communicate issues clearly and timely to members, providers, involved departments or health networks.
• Organize and manage activities related to processing cases within the department.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

EXPERIENCE & EDUCATION:

• High School diploma required.
• Active Licensed Vocational Nurse (LVN) license to practice in the State of California required.
• 5+ years of Healthcare/Managed Care experience required; preferably in related areas of responsibility of: Utilization Management, Quality Management, and Grievances, and Appeals.

PREFERRED QUALIFICATIONS:

• Active Registered Nurse (RN) license to practice in the State of California strongly preferred.
• Bilingual in English and in one of CalOptima's defined threshold language (Spanish, Vietnamese, Arabic, Farsi, Korean, or Chinese) is preferred.

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.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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Required Skills Required Experience

• Bachelor’s degree in architecture required
• 0 to 3 years’ experience; or equivalent in appropriate education and experience required. 
• LEED credential required within 6 months of employment.

HOK is a drug-free workplace.  HOK is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, age, genetic information, sexual orientation, gender identity, status as a protected veteran or status as a qualified individual with a disability, or any other characteristic protected by applicable Federal, State or Local law.