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Grievance & Appeals Nurse Specialist
| 2025-07-02 13:37:43
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Summary:

Description:

CalOptima Health is seeking a highly motivated TEMPORARY - 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: Grievance & Appeals
  • Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
  • Work Arrangement: Full Office 
  • Work Schedule:  Monday to Friday (8:00 a.m. - 5:00 p.m.) 

Submission Information:

  • The deadline to be guaranteed full review of your submission is due by Wednesday, July 2, 2025 by 9:00 p.m. PST.  This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.

Duties & Responsibilities:

  • 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.

Minimum Qualifications:

  • 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.

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!