Reporting to the Grievance & Appeals Regulatory Manager, the Grievance & Appeals Regulatory Nurse is responsible for working directly with providers, delegated entities, and internal IEHP departments in investigating and resolving cases, and responding to regulatory agencies to ensure compliance with internal Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations.
This position coordinates member care in conjunction with the member’s Providers to provide continuous quality care and assist in the development of quality initiatives.
The Grievance & Appeals Regulatory Nurse serves as a resource to IEHP personnel and providers.

Requirements

Three (3) or more years of experience with 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 required
Experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar) required
Experience in either State Fair Hearing (SFH) or Appeals or Grievances referred
Advanced professional reporting experience within Microsoft Excel preferred
Experience preparing professional, data driven narrative reports for all staff levels preferred
Legal processing experience preferred
High School Diploma or GED required
Bachelor’s degree in a Health-related field from an accredited institution preferred
Obtain Center for Medicare and Medicaid Services (CMS) Annual Certification within six (6) months of hire
Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN preferred
Valid California Driver’s License preferred
Knowledge of outside agencies and resources such as: CCS, CMS, DMHC, and DHCS
Knowledge of applicable laws, regulations, Welfare & Institution codes, assembly bills and All Plan Letters that are affiliated with the IEHP’s managed care setting
Generate written correspondence using appropriate grammar and punctuation
Microcomputer applications: spreadsheet, database, and word processing required
Excellent written and verbal communication skills
Proven ability to: Demonstrate critical thinking, good judgment, and strong problem-solving capability
Prioritize work to ensure adherence to project deadlines
Effectively escalate issues as identified, following established protocols
Demonstrate a commitment to incorporate LEAN principles into daily work
Show strong attention to detail
Possess a positive attitude and ability to work in a team setting
Exhibit flexibility in job roles and responsibilities
Express a strong drive to “do the right thing” and adhere to IEHP Mission, Vision and Values

Benefits

Competitive salary
Hybrid schedule
CalPERS retirement
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement 457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard skills

case managementutilization managementlegal processingdata driven narrative reportsreportingcritical thinkingproblem-solvingproject managementLEAN principlesattention to detail

Soft skills

written communicationverbal communicationgood judgmentteamworkflexibilitypositive attitudetime managementescalation of issuescommitment to qualityadherence to deadlines

Certifications

Vocational Nurse (LVN) licenseRegistered Nurse (RN) licenseCenter for Medicare and Medicaid Services (CMS) Annual Certification