Grievance Nurse

Lumeris Saint Louis , MO 63150

Posted 5 months ago

In order to apply for a position at Lumeris, you must create an account using your email address and a password of your choosing. This account will allow you to receive notifications each step of the way through the job application process. With these updates, you'll never have to wonder where you are in the process. Additionally, we can easily send pertinent documents to you for your review. Once you create the account, you may apply to any position you feel is a good fit without having to re-enter information. Thank you for your interest in Lumeris.

Position:

Grievance Nurse

Position Summary:

The Grievance Nurse is responsible for investigation, monitoring and reporting of Quality of Care, Quality of Service and Serious Reportable Adverse Events according to Center for Medicare and Medicaid Services (CMS) guidelines and plan policies and procedures. The Grievance Nurse will complete medical record reviews for re-credentialing and support activities related to Quality Improvement initiatives.

Job Description:

Roles and Responsibilities:

  • Conducts review of member grievances related to Quality of Care and Quality of service issues

  • Prepares reports to support CMS reporting requirements for quality topics such as Serious Reportable Adverse Events

  • Conducts medical record reviews to support regulatory requirements for the purposes of re-credentialing, Star Ratings and Medicare quality indicator reporting as needed.

  • Extracts, collects, analyzes and summarizes performance data for quality of care issues, quality initiatives, surveys, and audits

  • Performs comprehensive and accurate documentation to ensure grievances are handled in accordance to CMS guided regulations

  • Performs provider and member outreach

  • Assists in preparing for internal and external audits

  • Recognizes urgent issues and escalates to management in a timely manner to help facilitate a response

  • Participates in Quality Improvement initiatives

  • Performs other duties as assigned to meet departmental and company objectives

Experience, Qualifications, and Education:

  • RN required

  • Bachelor's Degree in a health-related field

  • 2+ years of experience in Quality Improvement

  • 2+ years of experience in Managed Care

  • 2+ years of experience with regulatory-required initiatives

  • Proficiency with clinical data management and statistical quality tools

  • Proficiency with MS Office applications

  • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action

  • Excellent verbal and written communication skills

  • Ability to work independently and meet deadlines

  • Ability to operation in fast paced and dynamic environment

  • Collaborative and team orientated

  • Strong logical and critical thinking skills

Lumeris is an EEO/AA employer M/F/V/D.

Location:

St. Louis, MO

Time Type:

Full time


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