Mark Powers

NEW!  

Resume Requirements:

• Legal First, Middle, and Last Name
• Phone number on resume
• No HSS Letterhead
• Need City, State, and Zip Code at top of resume
• Need License # on Resume
• MUST make sure employment dates and employer names are accurate. We run an employment verification during onboarding that will go based on the dates on the resume. 

Submittal Requirements, need answers to these questions:

• Legal First, Middle, and Last Name
• Is candidate a veteran?

HSS Job Title: LVN Grievance and Appeals Nurse Company Job Title: Temporary Grievance & Appeals Nurse Working with HR, Brian Sanchez – Mng is Charlyn Jones Req:  2026-6616 Background Check requirements: Criminal, Education Verification, Employment Verification, DMV report, Drug Test, Physical required  # of Openings: 2 positions If Contract, Length of Assignment: 6 month contract, eligible to apply to internal positions after 6 month contract is complete MU: 46% Compensation Notes: $30.72 (salary grade 112) Shift: M-F, 8-5 PST Start Date: will confirm once clear Interview Times/Interviewer: Teams interview with Cecillia Padron  Location: Remote.  Training will be onsite, must be willing to come in to the office for training if needed, need to be within 1-2 hours of Rancho Cucamonga - 10801 6th St STE 120, Rancho Cucamonga, CA 91730 Minimum Education/Licensures/Qualifications:

• High school diploma or GED (Bachelors preferred)
• Clear and active LVN license in CA (RN preferred)
• 2+ years of experience with case management, utilization management in managed care setting or related experience in a health care delivery setting
• Grievance and Appeals knowledge required

• 1 year in an HMO or MCO setting preferred
• Must have a valid California Driver's License.
• Knowledge of: 
  • Medi-Cal and Medicare benefits/regulations
  • Clinical review processes including how to analyze and research clinical issues.
  • Appeals and grievance processes.
  • Outside agencies and resources such as; CCS, CMS, DMHC, or DHCS.
• Ability to:
  • Ability to demonstrate critical thinking and strong problem-solving capability.
  • Strong attention to detail.  
  • Ability to prioritize work to ensure adherence to project deadlines.
  • Positive attitude and ability to work in a team setting.
• Computer Skills - Word, Outlook, and Advanced Excel experience

Position Summary/Position:

• The Grievance & Appeals Nurse is responsible for working directly with the IPAs, Hospitals, internal IEHP departments, and the grievance team to ensure grievance and appeal cases are processed per the Grievance Policy & Procedures and Department of Managed Health Care (DMHC)/ Department of Health Care Services (DHCS)/ Center for Medicare and Medicaid Services (CMS) regulations and NCQA. Coordinate care of Members in conjunction with the Member’s PCP and IPA and/ or IEHP Team Members to provide continuous quality care and assist in the development of quality initiatives. The Grievance & Appeals Nurse serves as a resource person to IEHP personnel, as well as external practitioners and Providers. When designated, the Grievance and Appeals Nurse will also be responsible for triaging and assigning grievance and appeals cases to ensure timeliness and regulatory requirements are met.

 

• Day to Day duties
• Implement management of grievance and appeals cases ensuring compliance with state and federal guidelines, including Centers for Medicare, and Medicaid Services requirements. Ensure all team grievance and appeals cases are processed thoroughly and timely as outlined in IEHP policy and procedures and regulatory guidelines.
• Ensure all member grievance issues are investigated and care is coordinated appropriately and in adherence to Grievance and Appeals Policies and Procedures. Work closely with the Grievance and Appeals Team under the direction of the Grievance Nurse Leadership with Member Services, Provider Services, Compliance, Medical Services Departments, and DMHC/DHS/CMS in reviewing grievance issues.
• Review case coding to ensure it is accurate, assist in the resolution of member medical issues and assist with coordination of care with all practitioners, Providers and entities/agencies involved in the member’s care.
• Resolve medical grievances, in conjunction with IEHP staff, Grievance Management, and Providers, as applicable.
• Identify case issues, assist in developing quality initiatives, referrals to outside agencies, other system issues within Grievances and Appeals and referring to appropriate IEHP Team Members.
• Assist with interpreting departmental policies, procedures, regulations, benefits (including evolving benefits), and other processes for IEHP members.
• Serve as a subject matter expert for grievance and appeals and is a resource for clinical and non-clinical Team Members in expediting the resolution of outstanding issues.  Maintain all grievance and appeals documentation according to external agency requirements. Serve as a resource for IEHP departments, as well as direct Grievance & Appeals Team Members.
• Notify Grievance & Appeals management of any identified trends related to contracted practitioners and Providers to assure continuity of care for identified IEHP members.
• Ensure clinical oversight of assigned Grievance and Appeals team cases, to include final nurse review of all Non-Quality of Care grievance and appeals cases and thorough investigation of all Quality-of-Care cases to be reviewed by IEHP Medical Director and designated Nurse Reviewer. Responsible for initial medical review and clinical oversight of all received team cases.
• Ensure all necessary follow up is tasked for completion by designated MedHOK business partners.
• Generate written correspondence to Providers, members, and regulatory entities utilizing approved templates with use of appropriate grammar and punctuation.
• Work with Team Members to support the protocols and goals of the department and the vision of the organization.
• Triage new cases to identify medical urgency and the potential need for Organizational Determination and notify the Immediate Needs team to ensure timely resolution.
• Complete Quality Assurance Reviews on all new grievance and appeal cases for correct classification, categorization, documentation of dates, source, line of business, requestor, and priority. Identify potential additional grievance or appeal cases necessary and open as needed.
• Audit daily reports to assure all grievance and appeal cases are captured and opened within regulatory timeframes. Ensure the log of all cases are opened and/or reviewed is maintained.
• When designated, assign new grievance and appeal cases to the appropriate team for investigation and resolution.
• Comply with mandated reporting obligations and serve as the first line to report allegations of physical and sexual abuse to the appropriate authorities.
• Prepare recommendations to either uphold or deny appeal using appropriate hierarchy criteria and forward to Medical Director for approval.
• Prepare files for Grievance and Appeals Committee reviews.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

RESUME EXAMPLE Relevant Skill Set: • Compassionate and detail-oriented Utilization Review Nurse with over 15+ years of experience in managed care and reviewing record for medical necessity and appropriateness of care utilizing InterQual and Milliman Care Guidelines. • Clear and active CA LVN license: #230258 (Exp: 11/30/2025) • Skilled in conducting prior authorization reviews, supporting fair resolution of member appeals, performing referral evaluations, and auditing medical records to ensure compliance with care standards. • Proven track record of supporting quality and cost-effective patient outcomes through thorough assessment of care appropriateness. • Adept at collaborating with multidisciplinary teams to optimize patient care plans and align with organizational protocols. • Knowledge of Medicare, Medicaid, Commercial Insurance, ICD 10, Prior Authorization Review/Decision Hierarchy, etc. • Proficient in MS Office, EPIC, InterQual, Milliman Care Guidelines etc. Professional Experience: CalOptima 12/2024 – 06/2025 LVN Prior Authorization Nurse (Contract completed) • Reviewed and processed prior authorization requests for outpatient services, DME, home health, medications, and specialty care. • Applied InterQual/MCG criteria to determine medical necessity and appropriateness of requested services. • Collaborated with RNs, physicians, pharmacists, and internal departments on complex cases and escalated denials. • Ensured accurate documentation of clinical decisions and maintained regulatory compliance with Medi-Cal and Medicare requirements. • Communicated with providers and members to clarify clinical information, request additional documentation, and explain authorization outcomes. • Supported the grievance and appeals process by preparing summaries and documentation for medical reviews. United Health Group (Dignity Health) 01/2020 – 04/2020; 05/2024 – 09/2024 Utilization Management / Prior Authorization Nurse (Contracts completed) • Conducted thorough prior authorization reviews to assess medical necessity and adherence to evidence-based guidelines, ensuring appropriate utilization of resources. • Processed appeals and grievance cases, reviewing denied claims and providing clinical rationale for upholding or overturning previous decisions. • Performed referral reviews to confirm the appropriateness of services, reducing unnecessary care and improving patient outcomes. • Audited medical records in response to requests, evaluating care appropriateness and compliance with policy standards, providing detailed reports on findings. • Collaborated with providers to facilitate continuity of care, optimize treatment plans, and enhance patient satisfaction. • Utilized InterQual and Milliman criteria to support decisions and ensure alignment with regulatory requirements and organizational standards. • Contributed to quality improvement initiatives by identifying trends in utilization and suggesting process enhancements. Riverside University Health System; County of Riverside 11/2020 – 08/2023 Licensed Vocational Nurse • Administered vaccines and medications to the patients • Recorded signs, intake medical history, enter labs Optimum 11/2018 – 01/2019 Authorization Review Nurse Consultant (contract completed) • Performed telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations. • Completed medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings. • Collaborated with various staff within provider networks and case management team electronically or telephonically to coordinate member care, educate providers on utilization and medical management processes. • Provided clinical knowledge and act as a clinical resource to non-clinical team staff, and enter and maintain pertinent clinical information in various medical management systems. United Health Group 06/2018 – 09/2018 Utilization Review LVN (Contract completed) • Performed clinical quality Case Reviews to include case preparation for Physician Peer Review Committee meetings, ensure that clinical grievances, complaints and complex issues are investigated and resolved. • Ensured follow - up actions items are communicated to the Plan and Providers in a timely manner, engage with physician and physician staff regarding PCP office performance, and working on various Quality Initiatives. Holistic Care Hospice 11/2016 – 06/2017 LVN • Direct patient care in a LTC facility, medication administration, supervision of subordinates, computerized documentation • Provide skilled nursing and palliative care for assigned hospice patients, work cooperatively with the other Kaiser Permanente 06/2003 – 06/2016 Utilization Review Specialist • Developed processes within the Utilization Management departments for requesting clinical information for concurrent review with strict adherence to guidelines, presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging and peer-to-peer reviews • Assisted with reviewing denied claims and collaborated with appeals teams to prepare clinical determinations • Collaborated with assigned case manager to identify members frequent hospital readmission, verified with Agency Policy and Procedure, State, JCAHO, and Guidelines, and managed various insurance reviews and subpoena for taxpayer inquiries. Education: LVN Diploma Four D College – Colton, CA