Virginia Premier Health Plan, Inc.

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Grievance and Appeals Nurse - LPN

Grievance and Appeals Nurse - LPN

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4268

Job Description

Overview

The Grievances/Appeals Nurse will be responsible for informing and educating plan members and practitioners on the process to properly submit a formal grievance and/or appeal.  The incumbent of this position manages, investigates and resolves member grievances/appeals or practitioner appeals, on behalf of the member, pursuant to Virginia Premier Health Plan (VPHP) policies and procedures, NCQA, DMAS and other accreditation or regulatory entities, as required to include, but not limited to, meeting all timeframes. The Grievances/Appeals Nurse shall be responsible for the intake of Grievance and Appeals when needed and also be responsible for serving as the plan’s liaison for the members and practitioners.  The Grievances/Appeals Nurse will perform grievance and appeals duties throughout all lines of business including Medicaid and Medicare lines of business. 

Responsibilities

  • Responds to member and practitioner grievances/appeals with minimal direction
  • Investigates and resolves member and practitioner grievances/appeals within plan, regulatory and accreditation timeframes
  • Represents and attends grievances/appeal hearings, as required
  • Prepares all grievances/appeals written documentation
  • Documents all grievances/appeals in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive and clearly defined files
  • Coordinates, communicates and integrates recommendations from impacted organizational departments and/or Senior Level Executives, as required
  • Generates reports with trend analysis and recommendations for quality improvement to Manager, as required
  • Communicates detailed account of risk management issues to the Manager within the specified timeframe
  • Provides timely assistance to members and practitioners in filing a formal grievance/ appeal and ensures that members and practitioners are advised of their appeal rights
  • Assists with training and in-services
  • Maintains strict confidentiality
  • Maintains current knowledge of VPHP policies and procedures
  • Participates in continuing education activities, as appropriate
  • Is fully trained on the Grievance and Appeals Coordinator position to provide redundancy when the Grievance and Appeals Coordinator is out of the office or is behind, in order to maintain time frames required by our State agency, DMAS

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Licensed Practical Nurse Required (Must have a valid up-to-date Virginia License)
  • Bachelor’s Degree preferred 

SPECIAL KNOWLEDGE AND/OR SKILLS 

  • Working knowledge of the Grievances/Appeals Processes and related legislation
  • Strong written and oral communication skills
  • Exceptional interpersonal and problem solving skills
  • Positive and approachable demeanor
  • Flexible (Outside of the Box) Thinker
  • Must be able to multi-task
  • Knowledge of medical terminology
  • Knowledge of the managed care industry
  • Demonstrated experience in quality project management from start to finish to include, but not limited to, receiving a request, data/document finding, ensuring proper and timely assessment of data by the appropriate staff, resolution and follow-up, as required
  • Computer experience with Microsoft office software including Access and Excel

WORK BACKGROUND/EXPERIENCE

  • Customer service experience in a medical environment
  • Experience applying accreditation and regulatory requirements and ensuring ongoing compliance
  • Ability to succinctly deliver pertinent information to a variety of audiences to include members, practitioners, organizational executives, attorneys and/or accreditation and regulatory auditors
  • Working knowledge of computers and word processing programs
  • Experience working with low income, indigent and/or disadvantaged populations 

Eligibility Requirements

  • Willing and able to confirm to a pre-employment background check.
  • Willing and able to accommodate minimal travel as needed.

 

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position

 

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

 

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