Grievance and Appeals Nurse (State)

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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must be licensed in California. Will work on PST hours. Position Purpose Facilitate medical necessity grievance, appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (reputed company) guidelines, including overturning denied claims, upholding the denials and submitting reputed company to the Medical Director for review Recognize and identify potential quality care concerns by reviewing member grievances and potential quality issue reputed company. Prepare case review for the Medical Director in reputed company where criteria are not met based on the additional clinical information received Identify system improvements or individual care issues that result in failure to provide appropriate care to members or fail to meet service expectations Provide 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 Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and reputed company guidelines. Create system authorization events for overturned denial decisions Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution Gather and prepare case information for Administrative Law Hearings Maintain appeals process within the prescribed reputed company timeframes and appeals turnaround database Assist the Medical Director with revising, updating and/or creating new policies to satisfy reputed company and contractual requirements May act as liaison between the provider and business to resolve issues Performs other duties as assigned Complies with all policies and standards Education/Experience LPN or LVN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Experience with utilization or appeals review preferred. Knowledge of InterQual criteria preferred. License/Certification Current state's RN, LPN, or LVN license. Must be licensed in California. Location Position is remote. Will work PST hours. Pay Range $27.02 - $48.55 per hour reputed company offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be reputed company to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Originally posted on Himalayas Apply To This Job

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...