Grievance & Appeals Nurse Specialist

Company: CalOptima
Location: Orange
Posted on: June 29, 2025

Job Description:

Grievance & Appeals Nurse Specialist CalOptima CalOptima Health is seeking a highly motivated Grievance & Appeals Nurse Specialist to join our team. The Grievance and Appeals Nurse Specialist will participate in managing CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. The incumbent will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. The incumbent 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. The incumbent will clearly articulate the facts and CalOptima Health's position regarding disputes to the Administrative Law Judge hearing the case. The incumbent will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements. Position Information:Department: GA - Clinical TeamSalary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)Work Arrangement: Full Telework This position is eligible for telework in California. Duties & Responsibilities:80% - Program SupportParticipates 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 SupportAssists 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. Minimum Qualifications:High School diploma 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 be also qualifying. Preferred Qualifications: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). Required Licensure / Certifications:Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California. Knowledge & Abilities: 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. 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 Work Environment: If located at the 500, 505 Building or a remote work location:Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.There are no harmful environmental conditions present for this job.The noise level in this work environment is usually moderate. If located at PACE:Work is typically indoors in a clinical setting serving the frail and elderly.There may be harmful or hazardous environmental conditions present for this job.The noise level in this work environment is usually moderate to loud. If located in the Community:Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.Employee will occasionally work outdoors in varied temperatures.There may be harmful or hazardous environmental conditions present for this job.The noise level in this work environment is usually moderate to loud. About CalOptima Health:CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits & Wellness options:At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the 2025 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 16, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: https://jobs.caloptima.org/jobs/grievance-appeals-nurse-specialist-505-city-parkway-west-california-united-states-fba1c7d4-bc08-4e7f-91b1-6492ceec25a1 Copyright ©2025 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-8fa0c2de5a333c45b461fe7f782eeef4 Salary: . Date posted: 06/04/2025

Keywords: CalOptima, Fountain Valley , Grievance & Appeals Nurse Specialist, Healthcare , Orange, California