L.A. Care Health Plan · 15 hours ago
Lead Customer Solution Center Appeals and Grievances RN
Los Angeles, CA
Full-time
Hybrid
Senior Level, Lead/Staff
$102K/yr - $163K/yr
8+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, providing health coverage to low-income Los Angeles County residents. The Lead Customer Solution Center Appeals and Grievances RN is responsible for developing a cohesive clinical unit for Appeals and Grievances, ensuring quality review of complex cases, and mentoring staff to improve customer service and compliance.
FitnessGovernmentHealth Care
Responsibilities
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
Prepares and reviews A&G files for submission to providers and internal departments
Work with other departments to ensure all aspects of a case are appropriately managed
Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met
Work closely with the leadership team to create and/or modify Desk Level Procedures and recommends enhancements to process and procedures
Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels
Recommend and implement resolutions, new processes, and/or process improvement
Provides accurate and timely written statistical reports that includes historical and/or current data to aid in projecting or evaluating compliance status
Identify and analyze trends in appeals and grievances to find the root cause of denials
Check, verifies and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance
Maintains documentation of all communications in the A&G system to ensure thorough tracking of case status
Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management
Work closely with management to review performance and quality standards on an ongoing basis
Acts as a back-up to the Supervisor in leading meetings and handling escalations as required
Perform other duties as assigned
Qualification
Required
Associate's Degree in Nursing for Registered Nurses
At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting
At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
At least 1 year of leading a process, program, or staff experience
Extensive knowledge of healthcare regulations and managed care guidelines
Demonstrated ability to provide recommendations towards resolution
Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity
Ability to communication, conflict resolution, and motivational skills
Ability to work independently and closely with a team in a collaborative and interactive environment
Ability to adjust to changing circumstances within the team
Good verbal and written communication skills
Licensed Registered Nurse (RN) - Active, current and unrestricted California License and/or Physician Assistant (PA) - California License Required
Preferred
Bachelor's Degree in Nursing for Registered Nurses
Clinical acute experience
Strong project management skills with the ability to manage multiple training initiatives simultaneously
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
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2025-08-27
2025-08-04
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