Hybrid Grievance & Appeals Regulatory Nurse

at IEHP

• Job title: Grievance & Appeals Regulatory Nurse
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $71,572 - $93,038 per year
• Degree requirement: High School Diploma
• Tech skills: Assembly
• Location requirements: Hybrid, United States

About the role

• Grievance & Appeals Regulatory Nurse coordinating member care and resolving cases for healthcare compliance. Serving as a resource between providers and regulatory agencies for quality care initiatives.

Responsibilities

• Reporting to the Grievance & Appeals Regulatory Manager, the Grievance & Appeals Regulatory Nurse is responsible for working directly with providers, delegated entities, and internal IEHP departments in investigating and resolving cases, and responding to regulatory agencies to ensure compliance with internal Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations.
• This position coordinates member care in conjunction with the member’s Providers to provide continuous quality care and assist in the development of quality initiatives.
• The Grievance & Appeals Regulatory Nurse serves as a resource to IEHP personnel and providers.

Requirements

• Three (3) or more years of experience with case management, utilization management in managed care setting or related experience in a health care delivery setting
• Experience in an HMO or experience in managed care setting required
• Experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar) required
• Experience in either State Fair Hearing (SFH) or Appeals or Grievances referred
• Advanced professional reporting experience within Microsoft Excel preferred
• Experience preparing professional, data driven narrative reports for all staff levels preferred
• Legal processing experience preferred
• High School Diploma or GED required
• Bachelor’s degree in a Health-related field from an accredited institution preferred
• Obtain Center for Medicare and Medicaid Services (CMS) Annual Certification within six (6) months of hire
• Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN preferred
• Valid California Driver’s License preferred
• Knowledge of outside agencies and resources such as: CCS, CMS, DMHC, and DHCS
• Knowledge of applicable laws, regulations, Welfare & Institution codes, assembly bills and All Plan Letters that are affiliated with the IEHP’s managed care setting
• Generate written correspondence using appropriate grammar and punctuation
• Microcomputer applications: spreadsheet, database, and word processing required
• Excellent written and verbal communication skills
• Proven ability to: Demonstrate critical thinking, good judgment, and strong problem-solving capability
• Prioritize work to ensure adherence to project deadlines
• Effectively escalate issues as identified, following established protocols
• Demonstrate a commitment to incorporate LEAN principles into daily work
• Show strong attention to detail
• Possess a positive attitude and ability to work in a team setting
• Exhibit flexibility in job roles and responsibilities
• Express a strong drive to “do the right thing” and adhere to IEHP Mission, Vision and Values

Benefits

• Competitive salary
• Hybrid schedule
• CalPERS retirement
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance