Grievance & Appeals Nurse Specialist New

Grievance and Appeals Nurse Specialist

Location: Orange, CA - Onsite

Length of Assignment: 6+ months

Pay: LVN - $43-$45/hr

RN: $45-$65/hr

Job Summary

The Grievance and Appeals Nurse Specialist manages medical appeals and state hearing reviews across all lines of business, handling both expedited and standard requests.

This role ensures compliance with regulations, policies, and procedures while preparing case narratives and position statements based on clinical information, benefits, and applicable regulations.

The specialist represents cases before Administrative Law Judges and reviews resolution letters for accuracy and adherence to clinical and regulatory standards.

Responsibilities

• Prepare clinical reviews using established guidelines; monitor cases involving medical decisions and quality of care.
• Ensure all cases meet state and federal regulatory requirements, including timelines.
• Present recommendations to physician reviewers for final determinations.
• Resolve complex and sensitive member issues within required timelines.
• Maintain departmental database integrity by accurately recording case actions.
• Analyze and report cases through GARS’ subcommittee.
• Oversee state hearing cases, explain appeal processes and rights to members, and coordinate services with providers.
• Draft position statements and represent the organization at state hearings.
  
  

Minimum Qualifications

• High School diploma required.
• 5 years of healthcare/managed care experience in Grievances & Appeals, Utilization Management, or Quality Management.
• Equivalent education and experience combination may be considered.
  
  

Preferred Qualifications

• Active Registered Nurse (RN) license in California.
• Bilingual in English and one of CalOptima Health’s threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
  
  

Licenses

• Active Licensed Vocational Nurse (LVN) license in California.
• Active Registered Nurse license in California
  
  

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