Nursing Jobs in La Habra, CA
$102,183 - $163,492 / year
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Lead Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all lines of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines. Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion. Duties Review and process complex and/or escalated clinical A&G cases. Analyze the patient medical records, clinical documentation, and insurance policies to determine medical necessity. Prepares and reviews A&G files for submission to providers and internal departments. Work with other departments to ensure all aspects of a case are appropriately managed. Conduct targeted and random clinical case audits to ensure that all regulatory and departmental guidelines, policies, procedures, and standards are met. Work closely with the leadership team to create and/or modify Desk Level Procedures and recommend enhancements to process and procedures. Assist the Clinical Supervisors in identifying deviations in performance and process changes are implemented to redirect performance to acceptable levels. Recommend and implement resolutions, new processes, and/or process improvement. Provide accurate and timely written statistical reports that include historical and/or current data to aid in projecting or evaluating compliance status. Identify and analyze trends in appeals and grievances to find the root cause of denials. Duties Continued Check, verify and ensure that all clinical A&G cases are processed accurately and within established timelines to meet or exceed member satisfaction goals and regulatory (CMS, DMHC, DHCS, NCQA), Health and Safety Code and company compliance. Maintain documentation of all communications in the A&G system to ensure thorough tracking of case status. Lead the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training, and feedback on performance to department management. Work closely with management to review performance and quality standards on an ongoing basis. As well as motivational programs needed to achieve regulatory standards. Act as a back-up to the Supervisor in leading meetings and handling escalations as required. Perform other duties as assigned. Education Required Associate's Degree in Nursing for Registered Nurses Education Preferred Bachelor's Degree in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting, At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment. At least 1 year of leading a process, program, or staff experience. Preferred: Clinical acute experience. Skills Required: Extensive knowledge of healthcare regulations and managed care guidelines Demonstrated ability to provide recommendations towards resolution. Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity. Ability to communication, conflict resolution, and motivational skills. Ability to work independently and closely with a team in a collaborative and interactive environment. Ability to adjust to changing circumstances within the team. Good verbal and written communication skills. Preferred: Strong project management skills with the ability to manage multiple training initiatives simultaneously. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information This position requires work after hours, on weekends, holidays, a hybrid remote schedule, and occasional flexibility in hours/shift in critical situations and work on-call. This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO) 
$101,700 - $134,900 / year
The rewards at Healogics are immense, starting with the important work we do to change patients’ lives. We also understand that meaningful work is hard work, and we are committed to supporting and compensating our employees for the tremendous service they provide. Think you are a great fit? Learn more about this role here: Healogics is the largest provider of advanced wound care services in the United States, treating more than 300,000 chronic wound patients annually across over 600 sites. With an aging society, obesity and diabetes on the rise, and an uptick in surgical procedures, the number of patients with non-healing wounds that would benefit from expert care is dramatically increasing. As a result, the company is working to provide our differentiated, quality outcomes to as many patients that would benefit through our out-patient clinic partnerships The Clinical Program Director is responsible for the management and the strategic growth of the Wound Care Program and other wound care continuum programs for the assigned area of responsibility. This position is responsible for the complete oversight of the Wound Care Center (WCC)®, to include the following functions: day-to-day center operations, staff management, financial management, quality/performance improvement, community education, and clinical functions oversight. The Clinical Program Director is also responsible for maintaining collaborative and consultative client relationships within and outside the hospital organization and for creating effective working relationships between Healogics and the hospital. All Healogics employees must perform their job responsibilities according to all Healogics policies, Hospital policies, as well as to accrediting organizations, federal and state regulation, and to the Centers for Medicare and Medicaid Services (CMS) guidelines, as applicable. Essential Functions/Responsibilities: (Percentage time shown in parenthesis next to each function) Manages the Center’s Operations (20%) Oversees the day-to-day management of outpatient clinic(s), and other wound care continuum programs, as applicable. Continuously assesses current clinic flows, processes and procedures, identifies areas of improvement, and develops and implements best practices and appropriate changes to improve outcomes Works with hospital and company personnel to ensure availability of adequate resources, supplies, equipment and services. Facilitates the flow of information and maximizes effective communication throughout the program. Prioritizes responsibilities and directs the work of the Center’s clinical staff and non- clinical staff. Collaborates with other health care providers across the wound care continuum, Wound Care Center (WCC)® Providers, and Medical Director regarding clinic and patient needs. May function as a Documentation Assistant (scribe) in accordance with Healogics policy Manages direct reports in conjunction with the company and hospital HR departments.This includes interviewing, hiring, motivating, coaching, counselling, establishing performance expectations, and conducting performance reviews. (5%) Performs Financial Management (10%) Manages and coordinates the revenue cycle for Healogics and for the hospital partner, as appropriate. Stays current with reimbursement changes, providing physician and staff updates and education as needed. Reviews key financial reports, identifies key indicator trends and develops plans to implement best practices to ensure fiscal responsibility. Tracks and reports all ancillary revenues generated by the program. Manages costs through appropriate utilization and management of labor and supply across the wound care continuum. Works with Healogics support team to complete financial reviews and presents results to hospital leadership. Manages Community Education/Marketing functions (20%) Works directly with the hospital and Healogics marketing departments to ensure that the wound care program has established strategic marketing plans and works with the same group and the hospital physician liaison to plan, coordinate, and execute activities directed toward increasing patient referrals to the Wound Care Center (WCC)®(s). Works collaboratively, as part of a multi-functional team, to best determine key target referral sources, and develops a systematic approach to build those customer relationships and increase Wound Care Center (WCC)® referrals. Maintains, monitors and updates the list of Physician Practices within a given radius of the hospital on an ongoing basis. Visits Physician Practices and interacts with key physicians to provide awareness of the Wound Care Center (WCC)® program, using educational marketing materials. Also documents all physician office interactions, as well as the visits with the Physician Practices in the Healogics Customer Relationship Management (CRM) system. Communicates on a regular basis with the (C)DO and/or (C)VPO and the hospital executive sponsor regarding goals, targets, and other relevant referral development information, as needed. Manages Quality/Performance Improvement functions (10%) Implements and manages a continuous Wound Care Center (WCC)® Performance Improvement Program (PIP) and strives to meet Wound Care Center (WCC)® quality indicators.Ensures program is integrated into the partner hospital’s PIP program. Participates in hospital committees as appropriate and ensures timely and accurate documentation in the patient record and outcomes database. Monitors patient, referring physician and customer satisfaction. Ensures that Patient Safety Guidelines are followed, that Healogics employees complete all annual requirements, including compliance requirements, and creates an environment that promotes the escalation of compliance concerns as appropriate. Manages clinical functions (20%) Is responsible for coordinating the clinical activities and directing the work of the clinical staff. This includes patient care assessment, patient care planning and implementation, and working on patient care quality improvement. The CPD partners with the for review of clinical practice. As needed, serves as case manager to a group of wound care patients, to include specific assessments and direct patient care according to protocols and procedures, clinical competence in procedural skills, treatments, and patient/caregiver education related to wound care management. Performs hyperbaric related duties, as needed, upon completion of the Healogics Hyperbaric training. May perform hyperbaric safety director duties after completing the required Healogics hyperbaric safety director training Manages Relationships (15%) Maintains excellent relationship with hospital client and continuously seeks to understand needs, confirm goal alignment and demonstrate value proposition.Identifies the hospital strategic goals and objectives and manages the program to achieve those goals, while remaining compliant with all Healogics operations standards. Works effectively and seamlessly at all levels within the partner hospital.Participates in hospital department/management meetings and actively participates in Hospital communication activities. Builds and develops effective working relationships with wound care program providers, clinical and support staff.Encourages all program staff to provide excellent customer service to members of other hospital departments. Performs other duties as required. Required Education, Experience and Credentials: Current Registered Nurse (RN) license to be maintained throughout the duration of employment in this position Bachelor’s degree in Business Administration, Healthcare Administration, Nursing or related field preferred and 1 year of marketing/community education in the healthcare industry or clinical operations experience OR Associate’s degree in Business Administration, Healthcare Administration, Nursing or related field preferred and 2 or more years of marketing/community education in the healthcare industry or clinical operations experience OR 4 years or more years of marketing/community education in the healthcare industry or clinical operations experience Management experience preferred Required Knowledge, Skills and Abilities: Demonstrated competency in BLS (Basic Life Support) Demonstrated knowledge of regulatory/accrediting requirements for healthcare organizations Proficient in Microsoft Office Suite (Word, Excel, Outlook and PowerPoint) Strong interpersonal, verbal and written communication skills, to include group presentation skills Strong analytical and quantitative skills Strong customer service and follow-up skills Strong organization, time management skills and ability to multi-task in a fast-paced environment Leadership and teaching skills Strong relationship building and influential skills Strong team building and motivational skills Ability to work with Healogics and hospital management. Budget and strategic planning skills Ability to travel overnight The salary for this position generally ranges between $101,700.00-$134,900.00 Annually This range is an estimate, based on potential employee qualifications: education, experience, geography as well as operational needs and other considerations permitted by law. If you are a current employee, to submit a job application, you need to apply as an internal candidate in Workday via the “Jobs Hub”. 
