The Clinical Nurse Specialist (RN Case Manager), is responsible for investigating and processing comprehensive and complex greivances and appeals requests from members and providers, coding justifications, and provider disputes. This position identifies through clinical review any system or processing issues that resulted in failure to provide
appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes. The Clinical Nurse Specialist has a dotted-line reporting relationship to the Chief Medical Officer.
EDUCATION OR TRAINING EQUIVALENT TO:
- Active and unrestricted California Registered Nurse; and
- Bachelor's degree preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- Minimum three years acute care clinical experience required;
- Minimum two years of experience in appeals and grievances casework required;
- Utilization Management or Quality Management experience preferred;
- Experience using standardized clinical guidelines preferred
- Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
- Strong knowledge of accreditation, federal and state regulations/requirements;
- Knowledge of risk management principles;
- Ability to effectively analyze, interpret, apply and communicate policies, procedures, provider
- contracts, and regulations;
- Strong analytical and problem solving skills;
- Excellent verbal and written communications skills;
- Excellent case preparation, clinical judgment, and abstracting skills;
- Team player who builds effective working relationships;
- Ability to work independently;
- Detailed knowledge of managed healthcare and Evidence of Coverage (EOC);
- Medical coding knowledge;
- Strong organizational skills; and
- Proficient in Microsoft Office suite including, Access and Project.