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Department

Must Be a Colorado Resident

Job Summary

Under minimal supervision, the Registered Nurse, Grievance & Appeals is responsible for assessing and completing appropriate documentation for tracking and trending, including conducting all pertinent research, in order to evaluate, respond, and close grievances and appeals for Denver Health Medical Plan's members, member representatives, contracted rental networks, hospitals, physician groups, primary care physicians, specialty care physicians and other individual health care providers in accordance with the Plan's adjudication and determination policies. Ensures that all Member Grievances and Appeals and Provider Resubmissions, Reconsiderations and Appeals, including all incoming correspondence, are properly processed on a timely basis.


Essential Functions:

• Maintains grievance and appeal information as well as supporting documentation in accordance with regulatory bodies for all lines of business at the Medical Plan. (10%)
• Notifies appropriate channels in compliance of all regulations and policies, while balancing the need to produce high quality work related to complex and sensitive issues. (10%)
• Proposes recommendations and decisions to all grievances and appeals through internal and external communications. (10%)
• Coordinates the compilation of appeal case files for transmission to third-party reviewers, physician reviewers, and independent reviewer entities. (5%)
• Maintains knowledge of current regulatory standards, internal policies, and procedures and ensures compliance at all times. (10%)
• Maintains knowledge and information on contract terms and benefit plans for all Plan lines of business. (5%)
• Consults and communicates effectively with Appeals Manager, senior leaders and other departments in the investigation and disposition of the grievance or appeals as deemed necessary or in compliance of regulatory requirements. (20%)
• Leverages both written and verbal communications; and ensures all provider resolution communications are timely, as well as organized, accurate, comprehensive, and crafted professionally. (10%)
• Conduct and Review Quality of Care Concern Complaints (10%)
• Perform Utilization Reviews for 1st Level Appeals by utilizing MCG (evidence-based medical criteria) (10%)

Education:

• Associate's Degree Registered Nurse required

Work Experience:

• 4-6 years clinical nursing experience required
• 1-3 years Managed Care Health Insurance or previous Grievance and Appeals experience preferred

Licenses:

• RN-Registered Nurse - DORA - Department of Regulatory Agencies required​

Knowledge, Skills and Abilities:

• Ability to investigate and analyze appeals with a level of thoroughness and in a timely manner.
• Ability to listen effectively and appropriately respond to difficult and urgent situations.
• Demonstrates strong analytical and research skills and the ability to solve problems creatively, objectively, and rapidly.
• Excellent interpersonal and verbal communication skills, including conflict resolution and mediation.
• Ability to write summaries, prepare reports, and write comprehensive letters using proper grammar and sentence structure.
• Must have a thorough understanding and working knowledge of managed care, health insurance plans, regulatory, and other policies and procedures, including grievance and appeals practices.
• Has critical thinking skills, ability to prioritize issues, handles sensitive issues with confidentiality, tact, and diplomacy.
• Ability to cope with a very high volume of tasks on a tight timeline under demanding conditions.
• Ability to adapt to a constantly changing environment and ability to work independently and with a team.
• Proficiency with the Microsoft Office Suite
• Experience with Data Entry Software
• Familiarity with various office equipment

Must Be a Colorado Resident

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.

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About Denver Health

Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.

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