Managed Care Nurse Grievance System Coordinator - Remote Position!
Managed Care Nurse Grievance System Coordinator - Remote Position!
Posted on :
23-08-2025
Employer Active
1 Vacancy
Job Alert
You will be updated with latest job alerts via emailValid email field required
Send jobs
Share
Send me jobs like this
Job Alert
You will be updated with latest job alerts via emailValid email field required
Send jobs
Job Description
We are currently hiring aREMOTE Nurse Grievance System Coordinator!If you are organized have excellent communication skills work well under pressure and tight deadlines and value being part of a team that makes a difference you may be the right person for the position!Apply today!
JOB SPECIFICATIONS
Classification:NON-EXEMPT Status:PART-TIME 28-HOURS/WEEK Business Operations are Monday - Friday generally 8am to 5pm Pacific Time
Salary:$34 - $50/HOURLY
Department:Grievance & Appeals Work Location:REMOTE local to Oregon
Reports to:Chief Compliance & Quality Officer
Supervision Exercised:Non-supervisory
Job Purpose: Grievance System Clinical Coordinator
This position is responsible for supporting the operations of the Grievance System by preparing clinically informed case files for review by physician-level decision-makers. Responsibilities include gathering and organizing medical records treatment history prior authorization data and applicable clinical guidelines to ensure thorough and timely case preparation. The role also includes coordinating the intake and resolution of member complaints and ensuring timely processing of grievances and appeals in compliance with all regulatory requirements. This position helps maintain adherence to required timelines under 42 CFR 438 Oregon Health Authority (OHA) contractual obligations and Section 1557 of the Affordable Care Act (ACA) ensuring members receive appropriate equitable and timely responses to their concerns.Qualifications Education & Experience
- Current unrestricted Oregon nursing license RN strongly preferred willing to consider LPN with strong clinical background
- Minimum three years experience in managed care or other healthcare setting
- Three years experience investigative reporting or information analysis required
- A high level of technological proficiency including the ability to navigate multiple software platforms simultaneously and quickly learn new systems and tools as needed is required
- Bilingual preferred qualified certified or willing to obtain
Essential Responsibilities: Grievance System Clinical Coordination
- Responsible for creating and maintaining positive relationships between the CCO its members and providers by promoting clear communication and equitable resolution of concerns.
- Manage the grievance and appeals process from intake to resolution including triage investigation and closure in compliance with 42 CFR 438.400438.424 OHA CCO contract requirements and internal policies.
- Gather and analyze comprehensive documentation from internal systems (e.g. authorizations claims care coordination notes) and external sources (e.g. provider records) relevant to grievances and appeals.
- Clinically contextualize appeal requests by summarizing medical records treatment timelines prior authorization and claims decisions and clinical guidelines for submission to Physician Reviewers.
- Maintain a current working knowledge of Oregon Health Plan (OHP) benefits medical necessity criteria covered services and CCO-specific clinical programs.
- Develop and maintain grievance and appeal policies and procedures including those governing clinical file preparation ensuring OHA approval and regulatory alignment.
- Collaborate with internal departments (Utilization Management Customer Service Claims) and external delegates to ensure consistent application of grievance and appeal procedures.
- Use internal tools and systems (e.g. claims systems EHRs case tracking software) to conduct investigations verify eligibility manage notification timeframes and confirm plan benefits and authorizations.
- As applicable assist in the preparation and tracking of medical records and member information release forms needed to process complaints and appeals or support administrative hearings.
- Apply clinical and critical thinking skills to correctly categorize appeal types (e.g. adverse benefit determinations expedited requests) determine review pathways and ensure appropriate reviewers are engaged.
- Ensure all grievance and appeal documentation is complete accurate and compliant including case categorization authorization adjustments and timely claims routing.
- Draft review and issue member and provider correspondence in accordance with OHA and federal timeframes ensuring language access requirements under ACA Section 1557 are met.
- Work independently under time-sensitive conditions to ensure timely closure of grievance and appeal cases in accordance with CCO OHA and CMS standards.
- Prepare complete and well-organized case files for internal audits and administrative hearings.
- Support member and provider education on grievance and appeal rights and procedural steps including explanation of clinical determinations when applicable.
- Maintain professional and objective communication with all stakeholders involved in complaints and appeals including medical providers members and external reviewers.
- Translate complex information related to clinical decisions benefit denials and regulatory requirements into clear accessible language for internal staff and external partners.
- Provide regular case trend reports to the Chief Medical Officer (CMO) and Chief Operating Officer (COO) including clinical insights escalation themes and recommendations for quality improvement.
- Uphold strict confidentiality and compliance with HIPAA CFR and CCO guidelines in handling protected health information (PHI) and sensitive case data.
- Monitor and report suspected fraud waste or abuse per company policy and contractual obligations particularly in cases involving clinical service disputes.
- Adhere to all applicable CCO state and federal policies and procedures related to grievance and appeals operations clinical case documentation and nondiscrimination (including ACA Section 1557).
- Perform other duties as assigned that support the goals of equitable timely and member-centered resolution of grievances and appeals.
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER
- Participate in quality and organizational process improvement activities when requested
- Support and contribute to effective safety quality and risk management efforts by adhering to established policies and procedures maintaining a safe environment promoting accident prevention and identifying and reporting potential liabilities
- Openly clearly and respectfully share and receive information opinions concerns and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers building bridges and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers which includes team members members students visitors and vendors by consistently exceeding the customers expectations
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
Knowledge Skills & Abilities:
- Advanced knowledge of Oregon State grievance appeals and administrative hearings rules and regulations.
- Advanced knowledge of Oregon Health Plan program requirements benefit package eligibility categories and Oregon Health Services Division rules and regulations.
- Advanced knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
- Knowledge of evidence-based practices and requirements to evaluate existing standards and implement new procedures
- Knowledge of current nursing practices
- Strong claims knowledge (ICD CPT and HCPCS codes) and authorization methodology
- Strong understanding of provider networks
- Knowledge of managed care concepts principles and operations
- Knowledge of administrative and clerical procedures
- Understanding of principles of health care of populations
- Knowledge of OHP program requirements benefit package eligibility categories and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
- Knowledge of the Oregon Health Authorities Coordinated Care Organization required metrics
- Critical attention to detail for accuracy and timeliness
- High degree of initiative judgment discretion and decision-making
- Ability to report to work as scheduled and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy Poverty Informed Systemic Oppression language access and the use of healthcare interpreters uses of data to drive health equity Cultural Awareness Trauma-Informed Care Adverse Childhood Experiences (ACEs) Culturally and Linguistically Appropriate Service (CLAS) Standards and universal access
- Knowledge and understanding of how the positions responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA HIPAA Waste Fraud and Abuse
- Awareness and understanding of equity diversity inclusion and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social political and environmental contexts of policies programs and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions conclusions or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations human needs and aware of how ones actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
Working Conditions:
This position must have the ability to remain in a stationary position occasionally move about inside the office to access office machinery printer etc. frequently communicate and exchange accurate information.
Work Condition: remote work
Employee generally works within a remote work from home environment.
Travel may be required on occasion.
Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:
Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
Machines equipment tools and supplies used:Constantly operates a computer or other office productivity machinery or software such as fax copier calculator multi-line telephone system or scanner.
May answer a high volume of telephone calls complete documentation and use computer programs to either obtain or record information.
Multiple Duties:Must be able to work under conditions of frequent interruption and be able to stay on task.
Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of DOCS Management Services employees. Other duties responsibilities and activities may change or be assigned at any time with or without notice.
Required Experience:
IC
Employment Type
Full Time
Key Skills
Report This Job
Disclaimer: Drjobpro.com is only a platform that connects job seekers and employers. Applicants are advised to conduct their own independent research into the credentials of the prospective employer.We always make certain that our clients do not endorse any request for money payments, thus we advise against sharing any personal or bank-related information with any third party. If you suspect fraud or malpractice, please contact us via contact us page.
