Grievance and Appeals Nurse Specialist

Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance and appeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of cases to ensure members receive high quality healthcare services. Working closely with PHC Medical Directors, oversees assessments for medically necessary determinations, quality of care concerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadership to Grievance & Appeals Case Analysts to ensure clinical solution followed on casework. Ensures casework complies with DHCS guidelines, NCQA standards, and PHC best practices. Works independently, prioritizes case deliverables, remains customer-focused and stays current on changes in the healthcare system that may trigger member dissatisfaction.

Assesses all cases to determine if members have any emergent or immediate medical needs. Identifies potential quality of care, fraud, waste, and abuse issues. Takes appropriate actions. Executes independent clinical judgement in assessing members concern, care and treatment. Evaluates and solves for any deviations in the standard of care, regulations, policy and procedures relevant to assigned cases. Conducts comprehensive clinical assessments as they relate to a member’s physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs. Takes appropriate actions. In coordination with the Grievance & Appeal Case Analyst, may contact members as it directly relates to their immediate clinical concerns. May refer to Care Coordination for continued/ongoing case management. Assesses and formally classifies disputed benefits according to NCQA pre-service and post-service classifications. Provides guidance to determine if/which medical records are needed to thoroughly evaluate the substance of on grievance and appeal cases. Evaluates all received medical records and writes clinical summary of observations in preparation of MD Director’s review. Medical records average 30-500 pages per case. Works closely with Grievance & Appeal Case Analyst, ensuring clinical content of resolution letters reflect clinical accuracy and medical terms are written in layman language Responsible for end-to-end investigation of exempt grievances. Works closely with PHC Medical Directors to identify and address concerns related to quality of care, HIPAA violations, fraud, waste, or abuse activity. Documents all casework activity thoroughly, accurately, timely, and ethically. Manages assigned cases so they are completed within DHCS timeframes, according to G&A Desktop procedures, and/or as directed by management. Serves as a clinical resource to the Grievance & Appeals team Identifies systematic or recurring issues that create barriers to high quality healthcare and reports them to leadership. Can work in a team environment Effective communicator in all modes of communication (e.g., written, verbal) May serve as a backup to absent Grievance & Appeals Nurse Specialists Attends meetings as needed including but not limited to Clinical Case Forum meetings, Department Meetings, and Division Meetings Maintains a Registered Nurse licensure in good standing Other duties as assigned.