Salary Range: $104,280 - $161,634
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.
FLSA Status: Exempt
Department: Quality Improvement
Reports To: Supervisor, Quality Improvement
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Grievance and Appeals Clinical Specialist performs clinical review of all appeals and grievances in accordance with applicable regulatory and professional standards using clinical experience and skills to assess, plan, implement, coordinate and evaluate to ensure appropriate clinical decision making. This role will be responsible for the clinical screening for quality of care in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
- Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective appeals within regulatory turnaround requirements for all SCFHP lines of business.
- Apply appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to issue appeals disposition and provide recommendations to a Medical Director.
- Perform clinical screening to determine the expedited review of grievance and appeals.
- Draft appropriate appeals notification letters to providers and members, following regulatory requirements.
- Assist the Grievance and Appeals Department in completing clinical appeals case summaries for submission to the Independent Review Entity, State Hearings and other escalated appeals.
- Identify potential quality of care issues in grievance and appeals and refer to the appropriate department(s) for further review and action, as needed. Assist with researching and reviewing Potential Quality of Care Issue (PQI) cases including case preparation and presentation to a Medical Director with a clinical recommendation for the severity level.
- Conduct telephonic and/or visits/assessments, as needed in the home, facility or community setting.
- Act as a clinical resource for Grievance and Appeals Department.
- Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS) and Quality.
- Participate in new and ongoing clinical Quality Improvement initiatives.
- Perform other duties as required or assigned.
REQUIREMENTS – Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
- Active California RN license without restriction. (R)
- Minimum three years of clinical experience. (R)
- Knowledge of managed care principles and practices with an emphasis in Grievance and Appeals and/or Utilization Management. (R)
- Knowledge of Medi-Cal and/or Medicare guidelines and regulations. (R)
- Experience in a Managed Care environment. (D)
- Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards. (D)
- Ability to make determinations based on nursing knowledge when no criteria are available or applicable. (R)
- Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
- Experience working with underserved member populations (e.g. behavioral health, seniors and persons with disabilities, children). (D)
- Ability to conduct home, facility and other community-based visits. (R)
- Maintenance of a valid California driver’s license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
- Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
- Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R)
- Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
- Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice. (R)
- Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
- Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
- Ability to maintain confidentiality. (R)
- Ability to comply with all SCFHP policies and procedures. (R)
- Ability to perform the job safely and with respect to others, to property and to individual safety. (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
- Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
- Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
- Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
- Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
- Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
- Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
EOE
Job Type: Full-time
Pay: $104,280.00 - $161,634.00 per year