LVN- Grievance and Appeals-Telecommute

Position Title: Grievance & Appeals LVN- MUST LIVE IN CA Location: Rancho Cucamonga, CA Schedule: 8a-5p Telecommute Length of position: 6 months, could be extended. Pay: $30/hour The Grievance & Appeals Nurse plays a key role in supporting members and ensuring their concerns are handled with care, accuracy, and in full compliance with state and federal regulations. This position works closely with IPAs, hospitals, internal departments, and the grievance team to review, process, and resolve grievance and appeal cases according to company policies and regulatory requirements (DMHC, DHCS, CMS, and NCQA). Key responsibilities include:

• Reviewing and coordinating grievance and appeal cases to ensure they are completed on time and meet all regulatory standards.
• Working with members, their PCPs, IPAs, and internal team members to support continuity of care and contribute to quality improvement efforts.
• Serving as a knowledgeable resource for staff, providers, and external partners regarding grievance and appeal processes.
• When assigned, triaging and assigning cases to ensure timely handling and proper documentation.

Working knowledge and understanding of: o Member and Provider legal rights to access the grievance and appeals resolution process, within the respective Provider Organization, DHCS, DMHC, and CMS and IEHP o Outside agencies and resources such as CCS, CMS, DMHC, or DHCS o Regulatory guidelines surrounding grievances and appeals per CMS, DHCS, and DMHC and NCQA Microcomputer applications: spreadsheet, database, and word processing. Excellent written and verbal communication skills Education: High school diploma or GED required Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting Experience in an HMO or experience in managed care setting preferred Associates degree from an accredited institution preferred Must have a valid California Driver's License Benefits:

• Medical, dental, and vision insurance, along with optional voluntary benefits (short-term disability, critical illness, accident plans)
• 401(k) retirement plan
• Direct deposit
• Continuing education opportunities and tuition discounts
• Referral bonus program up to $1,250

If you meet the qualifications and are interested in advancing your career with a leading healthcare staffing organization, apply today and a recruiter will contact you promptly. Apply To This Job