QM RN - Grievance & Appeals Review

Ensures that SCAN and it’s contracted network provide timely, appropriate quality of care and service to our members by overseeing the quality improvement activities conducted by the SCAN quality improvement staff.
Responsibilities:
Processes Grievances, Appeals, Quality Referrals, and Occurrences by establishing the issues of the case, ordering and collecting needed documents, reviewing the case documents, completing the Case Summary, and leveling the case or reviewing the Case with the Medical Director as appropriate.

Job Requirements



Education:
CA RN license required - Current and in good standing Degree in a related health care field preferred, at least 5 years clinical exp., at least 3 years exp. in Utilization Management, Quality Management, Risk Management. Excellent Critical thinking skills, 3 years with Managed Care, MS Word, Excel type 40 wpm