Lead Customer Solution Center Appeals and Grievances RN

Job Summary

The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit.

This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all line of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines.

Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.

Duties

Review and process complex and/or escalated clinical A&G cases. Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity. Prepares and reviews A&G files for submission to providers and internal departments.

Work with other departments to ensure all aspects of a case are appropriately managed.

Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met. Work closely with the leadership team to create and/or modify Desk Level Procedures and recommends enhancements to process and procedures.

Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels. Recommend and implement resolutions, new processes, and/or process improvement.

Provides accurate and timely written statistical reports that includes historical and/or current data to aid in projecting or evaluating compliance status. Identify and analyze trends in appeals and grievances to find the root cause of denials.

Duties Continued

Check, verifies and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance.

Maintains documentation of all communications in the A&G system to ensure thorough tracking of case status.

Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards.

Acts as a back-up to the Supervisor in leading meetings and handling escalations as required.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting,

At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment.

At least 1 year of leading a process, program, or staff experience.

Preferred:

Clinical acute experience.

Skills

Required:

Extensive knowledge of healthcare regulations and managed care guidelines

Demonstrated ability to provide recommendations towards resolution.

Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity.

Ability to communication, conflict resolution, and motivational skills.

Ability to work independently and closely with a team in a collaborative and interactive environment.

Ability to adjust to changing circumstances within the team.

Good verbal and written communication skills.

Preferred:

Strong project management skills with the ability to manage multiple training initiatives simultaneously.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, and occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.