Working Nurse · 1 month ago
Lead Customer Solution Center Appeals and Grievances RN
Los Angeles, CA
Full-time
Onsite
Senior Level, Lead/Staff
$102K/yr - $163K/yr
8+ years expWorking Nurse is the nation's largest publicly-operated health plan, dedicated to serving the community. The Lead Customer Solution Center Appeals and Grievances RN will oversee the development of the Appeals and Grievance clinical unit, ensuring quality review of complex cases and improving customer service outcomes.
Health CareHuman ResourcesRecruiting
Responsibilities
Assist with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit
Responsible for the quality review of complex and/or escalated clinical A&G cases for all line of business (LOB)
Assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership
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
Lead and work closely with assigned team daily
Mentor, coach, and may provide feedback to management on performance of staff
Ensure team effectiveness and project completion
Qualification
Required
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
Preferred
Clinical acute experience
Benefits
Great compensation and benefits
Company
Working Nurse
Working Nurse provides health care, human resources, and recruiting services.
2-10 employees
Funding
Current Stage
Early StageCompany data provided by crunchbase