Job Description

**Job Summary and Responsibilities** The Appeals and Grievances LVN is a critical role responsible for managing and resolving all medical necessity appeal requests from various stakeholders, including third-party payers, patients, and government entities. This individual acts as a primary liaison for clinical denials, navigating appeal processes through all delegated levels. Key responsibilities include intake, prioritization, and thorough review of appealed cases, ensuring all relevant documentation is presented to the Medical Director. The nurse must meticulously track and document all appeal activities, guaranteeing timely resolution in compliance with federal, state, and local regulations, including CMS guidelines. This role involves identifying necessary documentation for investigations, preparing files for regulatory appeals, and maintaining a detailed activity log for leadership review. The nurse will actively participate in audits, identifying and implementing process improvements to enhance efficiency and mitigate revenue loss due to denials. Staying current with plan policies and maintaining patient confidentiality (HIPAA) are also essential. Ultimately, the Appeals and Grievances Nurse monitors denial trends, recommends corrective actions, and provides regular reports to management and regulatory bodies, contributing to improved clinical quality and financial outcomes. *****Please note: This position is hybrid in-office/clinic and work from home.** **Job Requirements** **Minimum Qualifications:** - 2+ years administrative experience in a compliance auditing arena. Previous experience in a similar administrative or coordination role. - Associates degree, or 3 years of industry or job related experience, in lieu of a degree. - Clear and current CA Licensed Vocational Nurse (LVN) license. - Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements **Preferred Qualifications:** - Bachelors degree, or 5 years of industry or job related expereince, in lieu of degree, preferred. - Certified Compliance Professional (CCP), Certified Professional in Healthcare Quality (CPQH), Certified Healthcare Auditor (CHA) preferred. - 2 years managed care experience preferred. - 1 year delegation oversight experience preferred. - Regulatory audit experience preferred. - Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred - Knowledge of HIPPA, managed care environment preferred - Strong technical proficiency in data analysis; database software preferred - Familiarity with compliance requirements is a plus **Where You'll Work** Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service. One Community. One Mission. One California ( **Pay Range** $32.38 - $48.17 /hour We are an equal opportunity/affirmative action employer.

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Work at office, Local area,

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