Appeals and Grievances Nurse, LVN

We are hiring an Appeals and Grievances Nurse to join our team!

Remote - Must reside in California!

What You Will Be Doing:

Under general supervision, the Grievance and Appeals Nurse is responsible for investigating and processing grievances and appeals requests in compliance with internal and external requirements, and HPSJ strategies and objectives. Work is varied and moderately complex and requires a limited degree of discretion and independent judgment.

• Conducts investigations and reviews of member grievances and appeals.
• Reviews prospective, concurrent or retrospective medical records of denied services for medical necessity.
• Prepares and distributes case reviews, and recommendations as appropriate, to internal and external reviewers.
• Generates appropriate written correspondence to providers, members, and regulatory entities; collaborates with internal and external stakeholders to ensure reporting and letters are timely and accurate.
• Reviews member and practitioner Notice of Action letters to ensure regulatory compliance; documents findings and escalates as necessary.
• Investigates and perform clinical review of the IMR/SFH’s, submit health plan responses for IMR/SFH’s and participate in SFH’s as directed.
• Documents and maintains activities and records in appropriate HPSJ system(s) according to standards.

What You Bring:

• Strong clinical skills as defined in California scope of practice guidelines for LVN’s.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Ability to read, interpret and apply written regulations, guidelines and other materials; ability to read and interpret clinical information.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong analytical, assessment and problem-solving skills.
• Strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; includes the ability to effectively explain complex information.
• Ability to collaborate and work as part of a team.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Ability to enter data into and navigate through multiple databases.
• Strong customer service skills.
• Basic mathematics skills, including basic algebra.
• Intermediate skills in Word, Excel and Outlook, including the ability to develop spreadsheets, formulas, and create tables and graphs.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

Preferred

• Knowledge of Medi-Cal terminology, coding, acronyms, and general Medi-Cal procedures.
• Basic knowledge of the principles and practices of managed care.
• Basic knowledge of Medi-Cal and/or Medicare regulations as they apply to the appeal process.

What you Have:

Education and Experience

Required

• Graduation from an accredited nursing school; and
• At least three years clinical experience as an LVN in a healthcare setting.

Preferred

Licenses, Certifications

• Unrestricted California Vocational Nurse license; or
• Unrestricted Registered Nurse license.

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.