Grievance and Appeals Nurse Specialist

Job description

Overview Part of a multidisciplinary team, responsible for clinical oversight of assigned grievance andappeal cases. Utilizes clinical judgement in the assessment, solution, and/or guidance of casesto ensure members receive high quality healthcare services. Working closely with Partnership MedicalDirectors, oversees assessments for medically necessary determinations, quality of careconcerns, allegations of abuse, fraudulent acts or wasteful activity. Provides clinical leadershipto Grievance & Appeals Case Analysts to ensure clinical solution followed on casework.Ensures casework complies with DHCS guidelines, NCQA standards, and Partnership best practices.Works independently, prioritizes case deliverables, remains customer-focused and stays currenton changes in the healthcare system that may trigger member dissatisfaction. This position iseligible for teleworking. Responsibilities: - Assesses all cases to determine if members have any emergent or immediatemedical needs. Identifies potential quality of care, fraud, waste, and abuse issues.Takes appropriate actions. - Executes independent clinical judgement in assessing members concern, care andtreatment. Evaluates and solves for any...