Advanced Health Coordinated Care Organization
Managed Care Nurse Grievance System Coordinator - Remote Position!
Advanced Health Coordinated Care Organization, Oregon, Wisconsin, United States, 53575
Managed Care Nurse Grievance System Coordinator – Remote Position
Advanced Health Coordinated Care Organization is hiring a Remote Nurse Grievance System Coordinator. The role supports the operations of the grievance system by preparing clinically informed case files for review by physician-level decision‑makers and managing the intake, investigation, and resolution of member complaints.
Compensation Hourly: $34.00 – $50.00 per hour
Job Specifications
Classification:
Non‑Exempt
Status:
Part‑time, 28 hours per week (Mon‑Fri, 8am‑5pm PT)
Salary:
$34.00 – $50.00 per hour
Department:
Grievance & Appeals
Work Location:
Remote (local to Oregon)
Reports To:
Chief Compliance & Quality Officer
Supervision Exercised:
Non‑supervisory
Job Purpose The position is responsible for supporting the operations of the Grievance System by preparing clinically informed case files for review by physician-level decision-makers. Responsibilities include gathering and organizing medical records, treatment history, prior authorization data, and applicable clinical guidelines to ensure thorough and timely case preparation, coordinating the intake and resolution of member complaints, and ensuring timely processing of grievances and appeals in compliance with 42 CFR 438, Oregon Health Authority (OHA) contractual obligations, and Section 1557 of the Affordable Care Act (ACA).
Essential Responsibilities (Grievance System Clinical Coordination)
Create and maintain positive relationships between the CCO, its members, and providers.
Manage the grievance and appeals process from intake to resolution, including triage, investigation, and closure, in compliance with 42 CFR 438.400–438.424 and OHA CCO contract requirements.
Gather and analyze comprehensive documentation from internal systems (authorizations, claims, care‑coordination notes) and external sources (provider records).
Clinically contextualize appeal requests by summarizing medical records, treatment timelines, prior authorization and claims decisions, and clinical guidelines for submission to Physician Reviewers.
Maintain current knowledge of Oregon Health Plan (OHP) benefits, medical‑necessity criteria, covered services, and CCO‑specific clinical programs.
Develop and maintain grievance and appeal policies and procedures, ensuring OHA approval and regulatory alignment.
Collaborate with Utilization Management, Customer Service, Claims, and external delegates to ensure consistent application of procedures.
Use internal tools and systems (claims systems, EHRs, case‑tracking software) to conduct investigations, verify eligibility, manage notification timeframes, and confirm plan benefits and authorizations.
Assist in the preparation and tracking of medical records and member information release forms when needed.
Apply clinical and critical thinking skills to correctly categorize appeal types, determine review pathways, and ensure appropriate reviewers are engaged.
Ensure all documentation is complete, accurate, and compliant, including case categorization, authorization adjustments, and timely claims routing.
Draft, review, and issue member and provider correspondence in accordance with OHA and federal timeframes, ensuring language‑access requirements under ACA Section 1557 are met.
Work independently under time‑sensitive conditions to ensure timely closure of cases in accordance with CCO, OHA, and CMS standards.
Prepare complete and well‑organized case files for internal audits and administrative hearings.
Support member and provider education on grievance and appeal rights and procedural steps.
Maintain professional and objective communication with all stakeholders involved in complaints and appeals.
Translate complex information related to clinical decisions, benefit denials, and regulatory requirements into clear, accessible language.
Provide regular case‑trend reports to the Chief Medical Officer and Chief Operating Officer, including clinical insights, escalation themes, and recommendations for quality improvement.
Uphold strict confidentiality and compliance with HIPAA, CFR, and CCO guidelines in handling PHI and sensitive case data.
Monitor and report suspected fraud, waste, or abuse per company policy and contractual obligations.
Adhere to all applicable CCO, state, and federal policies and procedures related to grievance and appeals operations, clinical case documentation, and nondiscrimination (including ACA Section 1557).
Perform other duties as assigned that support equitable, timely, and member‑centered resolution of grievances and appeals.
Essential Responsibilities (Organizational Team Member)
Participate in quality and organizational process‑improvement activities when requested.
Support and contribute to effective safety, quality, and risk‑management efforts by adhering to established policies and maintaining a safe environment.
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner.
Work collaboratively by mentoring new and existing co‑workers and building rapport across the organization.
Provide excellent customer service to all internal and external customers, consistently exceeding expectations.
Recognize new developments and remain current in care‑management best practice standards.
Advance personal knowledge base by pursuing continuing education to enhance professional competence.
Promote individual and organizational integrity by exhibiting ethical behavior.
Represent the organization at meetings and conferences as applicable.
Qualifications, Education & Experience
Current, unrestricted Oregon nursing license. RN preferred; LPN considered with strong clinical background.
Minimum three years’ experience in managed care or other healthcare setting.
Minimum three years’ experience in investigative, reporting, or information‑analysis roles.
High level of technological proficiency, including ability to navigate multiple software platforms and learn new systems quickly.
Bilingual preferred or willing to obtain certification.
Knowledge, Skills & Abilities
Advanced knowledge of Oregon State grievance, appeals, and administrative hearings rules and regulations.
Advanced knowledge of Oregon Health Plan program requirements, benefit packages, eligibility categories, and Oregon Health Services Division rules.
Advanced knowledge of Medicare Parts A and B benefit packages and CMS rules and regulations.
Knowledge of evidence‑based practices and requirements to evaluate existing standards and implement new procedures.
Knowledge of current nursing practices and strong claims knowledge (ICD, CPT, HCPCS) and authorization methodology.
Knowledge of provider networks, managed care concepts, and administrative procedures.
Understanding of population health principles and OHP program requirements.
Strong attention to detail, initiative, judgment, discretion, and decision‑making.
Ability to work a flexible schedule when needed.
Proficient in Microsoft Office Suite and Windows OS.
Training or awareness of health‑literacy and equity‑focused frameworks (e.g., CLAS, trauma‑informed care, ACEs).
Awareness of equity, diversity, inclusion principles and ability to analyze systemic inequities.
Excellent interpersonal skills, friendly demeanor, and ability to communicate professionally both orally and in writing.
Ability to organize and function sensitively with diverse populations and cultures.
Working Conditions The position is remote; the employee must be able to remain stationary for periods of time, occasionally move around the office to access equipment, and communicate frequently. Remote work requires a stable internet connection and access to necessary technology. Occasional travel may be required. The role involves frequent use of a computer and electronic office software.
Additional Information This job description provides general information about the responsibilities for the role. It is not a comprehensive list and duties may change or be assigned at any time with or without notice.
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Compensation Hourly: $34.00 – $50.00 per hour
Job Specifications
Classification:
Non‑Exempt
Status:
Part‑time, 28 hours per week (Mon‑Fri, 8am‑5pm PT)
Salary:
$34.00 – $50.00 per hour
Department:
Grievance & Appeals
Work Location:
Remote (local to Oregon)
Reports To:
Chief Compliance & Quality Officer
Supervision Exercised:
Non‑supervisory
Job Purpose The position is responsible for supporting the operations of the Grievance System by preparing clinically informed case files for review by physician-level decision-makers. Responsibilities include gathering and organizing medical records, treatment history, prior authorization data, and applicable clinical guidelines to ensure thorough and timely case preparation, coordinating the intake and resolution of member complaints, and ensuring timely processing of grievances and appeals in compliance with 42 CFR 438, Oregon Health Authority (OHA) contractual obligations, and Section 1557 of the Affordable Care Act (ACA).
Essential Responsibilities (Grievance System Clinical Coordination)
Create and maintain positive relationships between the CCO, its members, and providers.
Manage the grievance and appeals process from intake to resolution, including triage, investigation, and closure, in compliance with 42 CFR 438.400–438.424 and OHA CCO contract requirements.
Gather and analyze comprehensive documentation from internal systems (authorizations, claims, care‑coordination notes) and external sources (provider records).
Clinically contextualize appeal requests by summarizing medical records, treatment timelines, prior authorization and claims decisions, and clinical guidelines for submission to Physician Reviewers.
Maintain current knowledge of Oregon Health Plan (OHP) benefits, medical‑necessity criteria, covered services, and CCO‑specific clinical programs.
Develop and maintain grievance and appeal policies and procedures, ensuring OHA approval and regulatory alignment.
Collaborate with Utilization Management, Customer Service, Claims, and external delegates to ensure consistent application of procedures.
Use internal tools and systems (claims systems, EHRs, case‑tracking software) to conduct investigations, verify eligibility, manage notification timeframes, and confirm plan benefits and authorizations.
Assist in the preparation and tracking of medical records and member information release forms when needed.
Apply clinical and critical thinking skills to correctly categorize appeal types, determine review pathways, and ensure appropriate reviewers are engaged.
Ensure all documentation is complete, accurate, and compliant, including case categorization, authorization adjustments, and timely claims routing.
Draft, review, and issue member and provider correspondence in accordance with OHA and federal timeframes, ensuring language‑access requirements under ACA Section 1557 are met.
Work independently under time‑sensitive conditions to ensure timely closure of cases in accordance with CCO, OHA, and CMS standards.
Prepare complete and well‑organized case files for internal audits and administrative hearings.
Support member and provider education on grievance and appeal rights and procedural steps.
Maintain professional and objective communication with all stakeholders involved in complaints and appeals.
Translate complex information related to clinical decisions, benefit denials, and regulatory requirements into clear, accessible language.
Provide regular case‑trend reports to the Chief Medical Officer and Chief Operating Officer, including clinical insights, escalation themes, and recommendations for quality improvement.
Uphold strict confidentiality and compliance with HIPAA, CFR, and CCO guidelines in handling PHI and sensitive case data.
Monitor and report suspected fraud, waste, or abuse per company policy and contractual obligations.
Adhere to all applicable CCO, state, and federal policies and procedures related to grievance and appeals operations, clinical case documentation, and nondiscrimination (including ACA Section 1557).
Perform other duties as assigned that support equitable, timely, and member‑centered resolution of grievances and appeals.
Essential Responsibilities (Organizational Team Member)
Participate in quality and organizational process‑improvement activities when requested.
Support and contribute to effective safety, quality, and risk‑management efforts by adhering to established policies and maintaining a safe environment.
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner.
Work collaboratively by mentoring new and existing co‑workers and building rapport across the organization.
Provide excellent customer service to all internal and external customers, consistently exceeding expectations.
Recognize new developments and remain current in care‑management best practice standards.
Advance personal knowledge base by pursuing continuing education to enhance professional competence.
Promote individual and organizational integrity by exhibiting ethical behavior.
Represent the organization at meetings and conferences as applicable.
Qualifications, Education & Experience
Current, unrestricted Oregon nursing license. RN preferred; LPN considered with strong clinical background.
Minimum three years’ experience in managed care or other healthcare setting.
Minimum three years’ experience in investigative, reporting, or information‑analysis roles.
High level of technological proficiency, including ability to navigate multiple software platforms and learn new systems quickly.
Bilingual preferred or willing to obtain certification.
Knowledge, Skills & Abilities
Advanced knowledge of Oregon State grievance, appeals, and administrative hearings rules and regulations.
Advanced knowledge of Oregon Health Plan program requirements, benefit packages, eligibility categories, and Oregon Health Services Division rules.
Advanced knowledge of Medicare Parts A and B benefit packages and CMS rules and regulations.
Knowledge of evidence‑based practices and requirements to evaluate existing standards and implement new procedures.
Knowledge of current nursing practices and strong claims knowledge (ICD, CPT, HCPCS) and authorization methodology.
Knowledge of provider networks, managed care concepts, and administrative procedures.
Understanding of population health principles and OHP program requirements.
Strong attention to detail, initiative, judgment, discretion, and decision‑making.
Ability to work a flexible schedule when needed.
Proficient in Microsoft Office Suite and Windows OS.
Training or awareness of health‑literacy and equity‑focused frameworks (e.g., CLAS, trauma‑informed care, ACEs).
Awareness of equity, diversity, inclusion principles and ability to analyze systemic inequities.
Excellent interpersonal skills, friendly demeanor, and ability to communicate professionally both orally and in writing.
Ability to organize and function sensitively with diverse populations and cultures.
Working Conditions The position is remote; the employee must be able to remain stationary for periods of time, occasionally move around the office to access equipment, and communicate frequently. Remote work requires a stable internet connection and access to necessary technology. Occasional travel may be required. The role involves frequent use of a computer and electronic office software.
Additional Information This job description provides general information about the responsibilities for the role. It is not a comprehensive list and duties may change or be assigned at any time with or without notice.
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