The Appeals and Grievance Clinical Specialist II is responsible for performing advanced and complicated case review of the appropriateness of medical care and service provided to members requiring considerable clinical judgment, independent analysis and detailed knowledge of managed health care, departmental procedures and clinical guidelines. Activities include research and case preparation. This position identifies system issues that result in failure to provide appropriate care to members or failure to meet service expectations.
Essential Duties & Responsibilities
Conducts clinical review and evaluation of member and provider appeals and grievance and potential quality of care concerns using considerable clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans to determine the appropriateness of care provided including, but not limited to:
- Reviews, triages and prioritizes cases to meet turnaround times. Expedites referrals to appropriate area or delegated entity to ensure access to appropriate care for members with current care needs and/or resolves appeal/grievances using expedited process;
- Acts as member advocate addressing member or provider concerns;
- Researches and analyzes complex issues. Acquires and reviews case against clinical records, clinical guidelines, policies, EOC/COI/Benefit Agreement, Benefit Policy and coding guidelines;
- Summarizes cases including articulation of member’s perception, initial denial determination and notification, analysis of medical records and application of all applicable policies, guidelines, benefit plans and laws, and rules and regulations;
- Prepares questions on complex cases for consultant review or external third party medical review;
- Develops determination recommendations that resolve member and provider disputes in a manner that is consistent with the requirements of regulatory and accrediting agencies, and supports health plan objectives;
- Presents cases to Medical Director and/or supervisor for review or determinations;
- Develops and/or reviews documentation and correspondence reflecting determination. Ensures accuracy, completeness and conformance to standards;
- Interacts with the provider, A&G staff, and other HN departments to ensure resolution of plan recommendations. Documents all activities as per unit practice including entry into automated systems;
- Recognizes potential quality care concerns.
- Prepares clinical summaries and assists HN Legal Department with litigation research.
- Identifies system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations:
- Provides input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions.
- May act as liaison between the provider and HN to resolve issues
- Provides feedback on the effectiveness of policies and procedures.
- Applies and interprets policies, procedures, clinical guidelines, medical policy, regulations and standards.
- Performs other duties as assigned.
- Graduate of an accredited nursing program
- Bachelor's degree preferred
- Active, valid, maintained & unrestricted state of CA Registered Nurse license required.
Government Clearance & US Citizenship Requirement
Minimum three years of clinical experience
Three to five years of utilization management or quality management experience strongly preferred
Experience in appeals and grievance casework
Experience using standardized clinical guidelines; InterQual experience preferred
- Or any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
Strong knowledge of accreditation, federal and state regulations/requirements
Knowledge of risk management principles
Strong analytical and problem solving skills
Excellent verbal and written communications skills
Excellent case preparation and abstracting skills
Team player who builds effective working relationships
Ability to work independently
Medical coding knowledge
Strong organizational skills
Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project
Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations
- The following section describes the general physical requirements for this position. Please note that ‘constant’ refers to more than 81% of time; ‘significant‘ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Significant phone usage; headsets may be required.
- Moderate lifting may be required. May need to lift, carry and/or move equipment/supplies weighing up to 20 pounds, always using safe lifting techniques.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
- Moderate walking/standing may be required. Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action
Employer - Minorities/Females/Veterans/Disability