Lead Customer Solution Center Appeals and Grievances RN

The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines.

Requirements

• Review and process complex and/or escalated clinical A&G cases
• Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity
• Conduct targeted and random clinical case audits
• Work closely with the leadership team to create and/or modify Desk Level Procedures
• Recommend and implement resolutions, new processes, and/or process improvement
• Provides accurate and timely written statistical reports
• Maintains documentation of all communications in the A&G system
• Leads the work of assigned staff and regularly assigns and checks the work of others
• Acts as a back-up to the Supervisor in leading meetings and handling escalations

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)