Appeals & Grievances Nurse - UCLA Health : Job Details

General Information

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Work Location: Los Angeles, USA

Onsite or Remote

Flexible Hybrid

Work Schedule

Monday-Friday, 8:00am-5:00pm PST

Posted Date

10/30/2024

Salary Range: $61.79 - 79.91 Hourly

Employment Type

2 - Staff: Career

Duration

Indefinite

Job #

20137

Primary Duties and Responsibilities

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As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You will:

* Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with clinical and administrative teams.

* Assessing cases to determine the appropriateness of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies.

* Identifying and investigating Potential Quality Issues (PQIs) to ensure continuous improvement in care delivery.

* Complete other duties as assigned.

Salary Range: $61.79-$79.91/hourly

Job Qualifications

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We're seeking a highly qualified candidate with:

* A BSN or MSN degree, required

* Current valid California RN license, required

* Minimum of 2 years' experience in a managed care or Medicare Advantage setting is highly desired

* Experience in handling appeals, grievances, utilization management, or potential quality issues

* Knowledge of Medicare Advantage plan operations and CMS regulations, highly desired

* Strong clinical assessment and decision-making skills, particularly in evaluating medical necessity

* Thorough understanding of Medicare Advantage regulations, especially related to appeals, grievances, and PQIs, highly desired

* Excellent written and verbal communication skills to communicate complex medical information to members and providers effectively

* Proficiency in Microsoft Office Suite and case management software

As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.