Grievance and Appeals Nurse Specialist Needed!

Position Responsibilities

• Prepares clinical reviews and provides monitoring of cases involving medical decisions and quality or care or service, and ensures all cases are completed in accordance with State and Federal regulatory requirements for timelines.

• Meets timeframes for performance with balancing the need to produce high quality work and resolving complex and sensitive member issues.

• Ensures integrity of departmental database and recording maintenance by thorough, timely and accurate entry of cases assigned.

• Assists with analyzing and reporting of cases through the GARS Subcommittee.

• Participates in departmental meetings, trainings and audits as requested.

• Oversight of State Hearing cases.

• Assists with the intake/notification process of cases in the department.

• Prepares position statements and represents company at State Fair Hearings.

• Other projects and duties as assigned.

Possess the Ability to:

• Analyze and complete written summaries on clinical cases.

• Conduct research on standards of practice, regulations and policy and procedures relevant to review cases.

• Provide oversight and training to staff on GARS procedures and requirements.

• Communicate issues clearly and timely to members, providers, involved departments or health networks.

• Organize and manage activities related to processing cases timely and accurately within the department and regulatory standards.