Grievance & Appeals Regulatory Nurse (Remote)

Date: Jan 24, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8671 


Position Summary/Position


Under the general direction of 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. Coordinate 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.

Major Functions (Duties and Responsibilities)


1. Responsible for the processing of all DMHC cases (Consumer Complaints and Independent Medical Reviews) and monitoring timeliness of responses.
2. Act as a primary contact between IEHP and regulatory agencies in resolving Member grievance and appeals by maintaining positive communication and working closely with IEHP Compliance and Legal Departments in resolving Members’ complaints, grievances, and appeals.
3. Responsible for the filing of Grievances and Appeals / Claim Dispute / request State Fair Hearing process; distinguishing between an inquiry, a Grievance, an Appeal, a Claim Dispute, and a quality of care issue and know how to triage, resolve, or refer incoming calls/correspondence to appropriate personnel.
4. Work closely with the Grievance and Appeals Team, with Internal Departments, and DMHC/DHCS/CMS to ensure all Member and Provider appeals are investigated, and care is coordinated appropriately.
5. Review Provider and Member appeals and/or complaints and make appropriate determination based on documentation presented by appealing agent with references to federal, state, and local regulations as well as IEHP policy and procedures based on line of business in a timely manner.
6. Responsible for the management of all incoming court documents related to State Fair Hearing (SFH) cases, including preparing for scheduled SFH cases, preparation of witness (e.g., Medical Director) and arranging for appearance / telephonic requests of witnesses as well as exhibit gathering.
7. Docket hearing notices, contact State / Office of Administrative hearings, establish duties and time frames in connection with each hearing and disseminate information with follow-up as appropriate.
8. Provide testimony on behalf of IEHP and administrative hearing and represent IEHP at hearing when necessary and appropriate.
9. Responsible for ensuring Member appeals are fully investigated, to ensure timely and accurate decisions to either uphold or overturn denial using appropriate criteria hierarchy and work closely with Medical Director for approval.
10. Ensure that written correspondence to Providers, Members, and regulatory entities is generated accurately and timely.
11. Responsible for identifying potential cases that are high risk and using critical thinking to escalate to Manager and make appropriate decisions.

Experience Qualifications


Two years or more (2+) 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. One plus (1+) years of experience utilizing Microsoft Word (create / edit documents), Outlook (send / receive emails, manage calendar).

Preferred Experience


Two (2) years of experience in either State Fair Hearing (SFH) or Appeals or Grievances preferred. Two (2) years of advanced professional reporting experience within Microsoft Excel preferred. Two (2) years of experience preparing professional, data - driven narrative reports for all staff levels preferred. Two (2) years of legal processing experience preferred.

Education Qualifications


Associate’s degree from an accredited institution required.

Preferred Education


Bachelor’s degree in a Health-related field from an accredited institution preferred.

Professional Certification


Center for Medicare and Medicaid Services (CMS) Annual Certification required. 

Professional Licenses


Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Knowledge of outside agencies and resources such as: CCS, CMS, DMHC, and DHCS.

Skills Requirement


Generates written correspondence using appropriate grammar and punctuation. Microcomputer applications: spreadsheet, database, and word processing required. Excellent written and verbal communication skills.

Abilities Requirement


Ability to demonstrate critical thinking, good judgment, and strong problem-solving capability. Ability to prioritize work to ensure adherence to project deadlines.  Ability to effectively escalate issues as identified, following established protocols.  Demonstrate a commitment to incorporate LEAN principles into daily work. Strong attention to detail.  Positive attitude and ability to work in a team setting. Flexibility in job roles and responsibilities. Strong drive to “do the right thing” and adhere to IEHP Mission, Vision and Values.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

A reasonable salary expectation is between $61,422.40 and $78,312.00, based upon experience and internal equity.

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles