Grievance & Appeals Nurse Specialist

Grievance & Appeals Nurse SpecialistCalOptimaJoin Us ‐ Where Your Talent Meets Opportunity. We're Better Together The Team You'll JoinWe are a mission driven community‐based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.More About the Opportunity We are hoping you will join us as a Grievance & Appeals Nurse Specialist and help shape the future of healthcare where you'll be an integral part of our Grievance & Appeals team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. You will participate in managing CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. You will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. You will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. You will clearly articulate the facts and CalOptima Health's position regarding disputes to the Administrative Law Judge hearing the case and also be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 80% ‐ Program Support Participates in a mission‐driven culture of high‐quality performance, with a member focus on customer service, consistency, dignity and accountability. Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions. Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines. Presents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination. Resolves complex and sensitive member issues within established timelines. Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases. Analyzes and reports cases through GARS' subcommittee. Oversees state hearing cases. Assists with the notification process to members or providers on the clinical decision issued. Discusses appeal process, medical decisions and hearing rights with members. Assists members in coordinating their services with providers and communicates the status and outcome to members. Assigns position statements and represents CalOptima Health at state hearings. 15% ‐ Administrative Support Assists the team in carrying out department responsibilities and collaborates with others to support short‐ and long‐term goals/priorities for the department. Participates in departmental meetings, trainings and audits as requested. 5% ‐ Completes other projects and duties as assigned. Do You Have What the Role Requires? High school diploma required PLUS 5 years of health care/managed care experience required, preferably in the following related areas of responsibility: grievances and appeals, utilization management and/or quality management; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. You'll Stand Out More If You Possess the Following: Current unrestricted Registered Nurse (RN) license to practice in the state of California. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese). What the Regulatory Agencies Need You to Possess? Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California. Your Knowledge & Abilities to Bring to this Role: Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem‐solve and possess project management skills. Work in a fast‐paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi‐program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Your Physical Requirements (With or Without Accommodations): Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face‐to‐face interactions. Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. Lifting and moving objects, patients and/or equipment 10 to 25 pounds Ways We Are Here For You You'll enjoy competitive compensation for this role. Our current hiring range is: Pay Grade: 313 ‐ $90,820 ‐ $145,312 ($43.66 ‐ $69.8615). The base pay offered will take into account internal equity and also may vary depending on the candidate's job‐related knowledge, skills, and experience among other factors. This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**) A comprehensive benefits package CalPERS pension program and additional retirement packages. Additional benefits and perks including: A generous PTO program A quality

Created: 2025-10-06