Appeals & Grievance RN

Location: Orange, CA
Date Posted: 12-31-2018
Quality Improvement RN – Managed Care
Orange, CA
** This is a full-time, benefits available, CONTRACT-TO-HIRE opportunity,
expected to convert to permanent positions after an established time frame! **
Quality Improvement Nurse Job Summary:
  • Responsible for Quality Improvement activities including Grievance and Appeals process and Statistical Reporting.
  • Review daily grievance and appeals from health plans, providers or members and request in writing to the appropriate facility or provider for any records and a response. Review with Medical Director on each case to determine leveling.
  • Update Grievance Appeal Logs daily and report to appropriate committees monthly.
  • Report statistical information on quality issues tracked by health plan and report monthly to the QI Committee.
  • Identify and act upon any provider/vendor trends immediately and informs Medical Director and QI Committee.
  • Prepare and develop annual QI study tools, gather and report statistical results to QI Committee, governing board and health plans. Study will be decided by QI Committee each year.
  • Participate and provide information for QI Plan and semi-annual coalitions.Implement annual QI study approved by QI Committee with policy, process flow, and action plan and report results when completed. (Access audits / coalitions / HEDIS)
  • Conduct Access and Availability audits per health plan request. Maintain departments access audits to include CSR, health plan or internal complaints.
  • Ensure access and availability log is updated weekly with trends reported to QI committee with follow-up and closure to be compliant.
  • Schedule appointments with physician offices and ancillary facilities for site reviews (facility and medical charts) as requested by the Credentialing Department.
  • Send confirmation letter with set appointment date and the site audit tool prior to appointment to provider office.
  • Report within 48 hours to the Credentialing Department the provider offices that do not meet threshold requirements for the audit and provide a copy of the review and notes after site audit is completed. 
Quality Improvement Nurse Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.).
  • Prefer Bachelors of Science in Nursing (BSN) or related healthcare field.
  • Certified Professional in Healthcare Quality (CPHQ) or certification in facility site reviews (FSR) is a plus.
  • Roughly 2-3 years acute care clinical nursing experience is required.
  • At least 3 - 5 years experience in a Medical Group or Health Plan QI department. 
  • Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
  • Knowledge of quality improvement / risk mitigation strategies in a managed care environment.
  • Analytical and problem solving acumen.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data analysis.
443.552.7423 (CALL – TEXT – FAX)
Schedule a time to talk by clicking HERE

Get Informed with
Managed Care News and more!
Sign-Up for Job Alerts
this job portal is powered by CATS