Grievance and Appeals Nurse (LVN)

About the position The Grievance and Appeals Nurse (LVN) at Kinetic Personnel Group is responsible for managing grievance cases within a public health plan. This role involves coordinating care with various stakeholders, ensuring compliance with regulatory guidelines, and serving as a resource for both internal and external parties. The position operates in a hybrid work environment, allowing for both remote and in-office work, and focuses on maintaining high standards of care and quality initiatives. Responsibilities • Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC. , • Understand Member and Provider legal rights to access grievance resolution process. , • Ensure compliance with state and federal guidelines including CMS requirements. , • Work closely with the Grievance & Appeals Team to investigate and coordinate care for Member grievances and appeals. , • Triage new cases to identify medical urgency and notify Immediate Needs team for timely resolution. , • Complete Quality Assurance Reviews on all new Grievance & Appeal cases. , • Audit daily reports to assure all Grievance & Appeal cases are captured and opened within regulatory timeframes. , • Assign new Grievance & Appeal cases to appropriate team for investigation and resolution. , • Comply with mandated reporting obligations for allegations of abuse. , • Review case coding for accuracy and assist in resolution of Member medical issues. , • Identify case issues and assist in developing quality initiatives. , • Prepare recommendations to uphold or deny appeals for Medical Director approval. , • Prepare files for Appeals Committee reviews. , • Serve as subject matter expert for appeals and assist clinical and non-clinical Team Members. , • Notify Grievance & Appeals Management of trends related to contracted practitioners. , • Conduct initial medical review and clinical oversight of received team cases. , • Support protocols and goals of department and organization. Requirements • Possession of a high school diploma or equivalent. , • Active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN. , • Two (2) years or more case management or utilization management experience in a managed care setting. , • Knowledge of outside agencies and resources such as CCS, CMS, DMHC. , • Valid California Driver's License. Nice-to-haves • Experience in Grievance & Appeals (2 years preferred). , • Experience in Utilization management (2 years required). Benefits • Health insurance , • Dental insurance , • Vision insurance Apply Job!