Judge Healthcare is seeking a Grievance & Appeals Nurse Specialist in Orange, CA!
Job Summary:
The Grievance and Appeals Nurse Specialist is responsible for managing medical appeals and state hearing reviews across all lines of business, including both expedited and standard requests. This role ensures that appeals and state hearing requests are processed in compliance with regulations, standards, and internal policies.
Key responsibilities include investigating and preparing case narratives and position statements based on clinical information, benefits, and relevant regulations. The specialist will clearly present the facts and positions regarding disputes to the Administrative Law Judge and will create and review resolution letters to ensure they meet clinical and regulatory requirements.
Position Responsibilities:
Conduct clinical reviews based on established guidelines and monitor cases involving medical decisions and quality of care.
Ensure all cases comply with state and federal regulatory requirements, including timelines.
Present recommendations based on clinical reviews, criteria, and organizational policies to physician reviewers for final determination.
Resolve complex and sensitive member issues within established timelines.
Maintain the departmental database and ensure the accuracy of case records.
Analyze and report cases through the GARS subcommittee.
Oversee state hearing cases, discuss the appeal process, medical decisions, and hearing rights with members.
Assist members in coordinating services with providers and communicate status and outcomes.
Assign position statements and represent the organization at state hearings.
Minimum Qualifications:
High School diploma.
5 years of healthcare or managed care experience, preferably in Grievances and Appeals, Utilization Management, or Quality Management.
Equivalent combinations of education and experience that provide the necessary skills to perform the job duties are also acceptable.
Preferred Qualifications:
Active Registered Nurse (RN) license in California.
Bilingual in English and one of these languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
Active Licensed Vocational Nurse (LVN) license in California.
If this sounds like something you'd be interested in hearing more about, please apply directly!
Christina Head, Sr. Healthcare Recruiter, Judge Healthcare
chead@judge.com
Contact: chead@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
