The Clinical Nurse Specialist, is responsible for investigating and processing comprehensive and complex grievances and appeals requests from members and providers, coding justifications, and provider disputes.  This position identifies through clinical review  any system or processing issues that resulted in failure to provide appropriate care to members, failure to meet service expectations, billing concerns, and provider disputes.  The Clinical Nurse Specialist has a dotted-line reporting relationship to the Chief Medical Officer. Principal responsibilites include: • Conducts investigations and reviews of member and provider medical necessity grievances and appeals; • Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity; • Extrapolates and summarizes medical information for Medical Director, consultants or other external review; • Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines; • Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval; • Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements; • Apply expedited criteria to recommend the appropriateness of urgent requests; • Documents and logs appeal/grievance/dispute information on relevent tracking systems; • Generates written correspondence to providers, members and regulatory entities; • Interact with members, providers and/or other staff to ensure resolution of plan recommendations; • Recognize potential quality of care concerns and refer to the Medical Director for review; • Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues. • Perform other duties and special projects as assigned.  

ESSENTIAL FUNCTIONS OF THE JOB • Conducts investigations and reviews of member and provider medical necessity grievances and appeals, coding justifications, and provider disputes; • Determine the appropriateness of care provided within the context of all applicable contractual requirements, state/federal regulations and accreditation standards; • Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement; • Perform writing, reporting, administration, and analysis; and • Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.  

PHYSICAL REQUIREMENTS • Constant and close visual work at desk or computer; • Constant sitting and working at desk; • Frequent use of keyboard and/or mouse; • Frequent use of telephone headset; • Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person; • Frequent lifting of folders and various objects weighing between 0 and 30 lbs; • Frequent walking and standing; and • Occasional driving of automobiles.  

MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: • Active and unrestricted California Registered Nurse; and • Bachelor's degree preferred.  

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: • Minimum three years acute care clinical experience required; • Minimum two years of experience in appeals and grievances casework required; • Utilization Management or Quality Management experience preferred; • Experience using standardized clinical guidelines preferred • Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred.  

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): • Strong knowledge of accreditation, federal and state regulations/requirements; • Knowledge of risk management principles; • Ability to effectively analyze, interpret, apply and communicate policies, procedures, provider contracts, and regulations; • Strong analytical and problem solving skills; • Excellent verbal and written communications skills; • Excellent case preparation, clinical judgment, and abstracting skills; • Team player who builds effective working relationships; • Ability to work independently; • Detailed knowledge of managed healthcare and Evidence of Coverage (EOC); • Medical coding knowledge; • Strong organizational skills; and • Proficient in Microsoft Office suite including, Access and Project.  

Pay Range: $77,710 - $116,570/annually