Medical Management Nurse Analyst - Administrative (On-site position)

Job Description

Job Description

POSITION SUMMARY:

This position functions as a member of the Medical Management team and is primarily responsible for reviewing Appeals & Grievances (A&G) cases, reconciling and maintaining tracking databases, and supporting case review activities for Oversight Audits. The role ensures data accuracy, supports audit readiness, and contributes to compliance with regulatory requirements.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Assists in maintaining standards that are in conformance with federal and state regulations and requirements.
• Gather, review and monitor regular clinical reports from Health Net.
• Perform (or assist with) annual oversight audits of HN clinical functions.
• Assist with preparation for external audits (DHCS, DMHC, NCQA) by gathering and reviewing required documents for clinical functions.
• Prepare/assist with audit summary reports and the implementation of any required corrective action plans.
• Participate as requested in HEDIS® Projects, the DHCS required Quality Improvement Projects, and other QI or UM activities, studies, reviews and surveys.
• Assist in the preparation of required CalViva clinical reports.

Minimum Qualifications:

Education:

Completion of an accredited nursing program

Licenses:

• Current California nursing license (R.N. OR L.V.N.)
• QI program certification a plus
• Current driver’s license

Experience:

• Minimum of two years’ experience in healthcare environment.
• Health Care Quality Improvement, data analysis, and/or auditing experience.

Knowledge, Skills & Abilities:

• Ability to effectively develop, analyze, interpret, and communicate healthcare data reports and processes.
• Strong analytical and problem-solving skills.
• Must be at least proficient in Microsoft Office: Word, Excel, PowerPoint, Access and Outlook.
• Possess the ability to prioritize projects appropriately and multi-task.
• Ability to take initiative and work independently.
• Effective organizational and communication skills.
• Team player who can establish and maintain effective working relationships at all organization levels.
• Exercise a high degree of maturity, integrity, loyalty, initiative, creativity and sound judgment.

Physical Requirements

• Constant and close visual work at desk or computer.
• Extensive typing
• Constant sitting and working at desk.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent walking and standing.
• Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lb.
• Must have reliable transportation, may be required to travel between Kings, Madera, and Fresno counties as well as between offices for meetings

Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.

CalViva Health is the Local Initiative Plan for Fresno, Kings and Madera Counties. CalViva Health is under the Medi-Cal Managed Care Program. It is sponsored by the Regional Health Authority, which offers local access, local control and local responsive health care.

Company Description

CalViva Health is the Local Initiative Plan for Fresno, Kings and Madera Counties. CalViva Health is under the Medi-Cal Managed Care Program. It is sponsored by the Regional Health Authority, which offers local access, local control and local responsive health care.