Clinical review and processing of member Appeal and Grievances, using considerable clinical judgment, case analysis, and detailed knowledge of organizational processes and regulatory guidelines. Participate with ongoing HEDIS/5 Star measurement and other QI activities.
Active, valid and unrestricted State of California nurse license required. 2-3 years of experience in Quality Improvement, with knowledge of managed care systems. Excellent written and oral communication skills. Strong organizational skills. Detail oriented with sharp critical thinking and problem solving skills. Able to operate PC-based software programs, including proficiency in Word, Excel, EZCAP and knowledge of NextGen/EHR. Excellent customer service and telephone skills with ability to interact effectively with internal/external customers. Current California driver's license and proof of automobile insurance.