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APPEALS AND GRIEVANCES COORDINATOR, RN in San Diego, CA at Scripps Health Plan Services -4S Ranch

Date Posted: 5/15/2019

Job Snapshot

Job Description

At Scripps Health, you will experience the pride, support, respect that has been repeatedly recognized as one of the nation’s Top 100 Places to work.
You’ll be surrounded by people committed to making a difference in the lives of their patients and their teammates.  So if you’re open to change, go ahead and unlock your potential.
This RN Quality Coordinator will primarily be responsible for the coordination of appeals, grievances and potential quality issue research and resolution.  Will ensure compliance with all State, Federal and Health Plan requirements for correspondence to communicate Appeal & Grievance (A&G) and Utilization Management (UM) decisions and Claims processing to include denials to members and providers as they relate to the A&G.  Responsible for ensuring accuracy and compliance of A&G logs, peer review databases and case files, as assigned.    Able to lead projects and facilitate work groups.  Documenting and managing patient relations including potential quality issues (PQI), and other clinical quality related initiatives.  Attention to detail and solid clinical skills ensure the quality processes aligns with the utilization management processes and all regulatory compliance requirements are met. 
This is an ideal position for an experienced clinical nurse that can multi-task, independently prioritize work as needed, have strong communication skills, and possess professional-level writing skills. 
The Quality Coordinator, RN manages publicly reported and other significant quality measures and performance improvement in collaboration with administrative, clinical and physician leadership for their assigned service line. Performs concurrent review of medical records for core measures and other clinical indicators based on established definitions and provides real time feedback and intervention with clinical staff and physicians to ensure optimal quality patient care.
This is a full-time, salaried position.

Job Requirements

Required Education/Experience/Specialized Skills:
  • 5 years of recent direct patient care experience or currently holding a coordinator/leadership level role within an acute care setting.
  • Requires attention to detail, analytical skills, excellent communication skills
  • Previous experience in quality improvement methods and tools required.
  • Familiarity with Department of Managed Health Care standards as they relate to Performance Improvement and/or Medical Staff Quality/Peer review strongly preferred.
Required Certification/Registration: Current RN License required.

Preferred Education/Experience/Specialized Skills/Certification:
  • Experience with appeals and grievances
  • Background in managed care
  • Training and application of MIDAS or like-data base strongly preferred
  • Bachelor’s degree strongly preferred.
  • Previous experience using Epic
Scripps Health is repeatedly named on the Fortune Magazine’s 100 Best Companies to work for, only San Diego-based Company and Becker’s Healthcare Top Hospitals. Scripps Health offers a robust Total Rewards Program designed to compensate and motivate you throughout your career. Scripps Health Total Rewards Program includes a broad range of plans and programs including market competitive pay and performance incentives, health and wellness benefits, financial wellness benefits, work-life resources, learning and development opportunities, and rewards and recognition. Unlock your potential with Scripps Health today.

Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.