[Hiring] Grievance & Appeals Nurse @Inland Empire Health Plan

Role Description

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Supervisor, Grievance & Appeals, the Grievance & Appeals Nurse, RN (G&A Nurse, RN) is responsible for:

• Working directly with the IPAs, Hospitals, internal IEHP departments, and the Grievance team to ensure Grievance and Appeal cases are processed per the Grievance Policy & Procedures and regulations.
• Coordinating care within the scope of their licensure, in conjunction with the member’s PCP and IPA and/or IEHP Team Members.
• Serving as a resource person to IEHP personnel, external practitioners, and providers.
• Triage and assign Grievance and Appeals cases to ensure timeliness and regulatory requirements are met.
• Supporting appropriate Grievance case categorization and completing required reporting to internal and external departments.

Commitment to Quality: The IEHP Team is committed to incorporating IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Qualifications

• Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting required.
• Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting required.
• Associate's Degree in Nursing from an accredited institution required.
• Bachelor's Degree in Nursing from an accredited institution preferred.
• Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required.

Requirements

• Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS.
• Understanding of patient rights and ethical decision-making frameworks.
• Knowledge of medical necessity and level of care, chronic disease, and complex clinical cases.
• Familiarity with regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA.
• Proficiency in microcomputer applications: spreadsheet, database, and word processing.
• Excellent interpersonal and communication skills.
• Time management and priority setting skills.

Benefits

• Competitive salary.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options.
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare.
• 457(b) option with a contribution match.
• Paid life insurance for employees.
• Pet care insurance.

Company Description

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location: Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership).

Pay Range: USD $91,249.60 - USD $120,910.40 /Yr.