RN-Appeals and Grievance Clinical Specialist II CA-Woodland Hills W / Telecommuting

Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable.

The Appeals and Grievance Clinical Specialist II is responsible for performing advanced and complicated case review of the appropriateness of medical care and service provided to members requiring considerable clinical judgment, independent analysis and detailed knowledge of managed health care, departmental procedures and clinical guidelines. Activities include case preparation, research and overturn determinations. This position identifies system issues that result in failure to provide appropriate care to members or failure to meet service expectations.

- Conducts clinical review and evaluation of member and provider appeals and grievance using considerable clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans to determine the appropriateness of care provided including, but not limited to: - Reviews, triages and prioritizes cases to meet turnaround times. Expedites referrals to appropriate area or delegated entity to ensure access to appropriate care for members with current care needs and/or resolves appeal/grievances using expedited process; - Acts as member advocate addressing member or provider concerns; - Researches and analyzes complex issues. Acquires and reviews case against clinical records, clinical guidelines, policies, EOC/COI/Benefit Agreement, Benefit Policy and coding guidelines; - Summarizes cases including articulation of member's perception, initial denial determination and notification, analysis of medical records and application of all applicable policies, guidelines, benefit plans and laws, and rules and regulations; - Prepares questions on complex cases for consultant review or external third party medical review; - Develops determination recommendations that resolve member and provider disputes in a manner that is consistent with the requirements of regulatory and accrediting agencies, and supports health plan objectives; - Presents cases to Medical Director and/or supervisor for review or determinations; - Develops and/or reviews documentation and correspondence reflecting determination. Ensures accuracy, completeness and conformance to standards; - Interacts with the member, provider and/or A&G staff to ensure resolution of plan recommendations. Ensures communication of member or provider rights; - Documents all activities as per unit practice including entry into automated systems; - Recognizes potential quality care concerns. - Prepares clinical summaries and assists HN Legal Department with litigation research. - Identifies system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations: - Collects, trends and monitors data; completes root cause analysis; - Provides input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions. - Acts as liaison between the beneficiary, provider and HN to resolve issues. - Prepares reports, data or other materials for committee presentation. - Provides feedback on the effectiveness of policies and procedures. - Applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards. - Performs other duties as assigned.

**Education** * Graduate of an accredited nursing program; B.S., Nursing preferred. **Certification/Licensure Required** * Active, valid, maintained & unrestricted state of CA Registered Nurse license required. **Government Clearance and US Citizenship Requirement** * N/A **Experience Required** * Minimum three years of clinical experience * Three to five years of utilization management or quality management experience strongly preferred * Experience in appeals and grievance casework * Experience using standardized clinical guidelines; InterQual experience preferred * Or any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. **Knowledge, Skills and Abilities** * Strong knowledge of accreditation, federal and state regulations/requirements * Knowledge of risk management principles * Strong analytical and problem solving skills * Excellent verbal and written communications skills * Excellent case preparation and abstracting skills * Team player who builds effective working relationships * Ability to work independently * Medical coding knowledge * Strong organizational skills * Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project * Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations **Working Conditions** * N/A