Grievance & Appeals Nurse Specialist - CalOptima : Job Details

Grievance & Appeals Nurse Specialist

CalOptima is seeking a highly motivated Grievance & Appeals Nurse Specialist to join our team. The role involves managing medical appeals and state hearing reviews across all lines of business, ensuring compliance with regulations and policies. The specialist will investigate disputes, prepare case narratives, and articulate positions clearly during hearings. Responsibilities include creating resolution letters and maintaining accurate records.

Position Information:

• Department: GA ‐ Clinical Team
• Salary Grade: 313 ‐ $90,820 ‐ $145,312 ($43.66 ‐ $69.86)
• Work Arrangement: Full Telework

Duties & Responsibilities:

Program Support (80%)

• Participate in a member-focused, high-quality performance culture.
• Prepare clinical reviews based on guidelines, monitor cases, and ensure regulatory compliance.
• Coordinate with physicians and present recommendations for final determinations.
• Resolve complex member issues within timelines and maintain accurate records.
• Oversee state hearing cases and assist with communication to members and providers.
• Represent CalOptima at state hearings.

Administrative Support (15%)

• Support departmental responsibilities, participate in meetings and audits.

Other Duties (5%) - Complete additional projects as assigned.

Minimum Qualifications:

• High School diploma + 5 years of healthcare/managed care experience, preferably in grievances, appeals, utilization, or quality management, or equivalent experience.

Preferred Qualifications:

• Current unrestricted RN license in California.
• Bilingual in English and one threshold language (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Licensure / Certifications:

• Current unrestricted LVN license in California.

Knowledge & Abilities:

• Build relationships with stakeholders.
• Work independently with sound judgment.
• Communicate effectively in writing and speaking.
• Flexible schedule, including evenings/weekends.
• Organize, analyze, and manage projects efficiently.
• Utilize computer software (Microsoft Office, etc.).

Physical & Work Environment:

Details on physical requirements and work settings are included, noting indoor/outdoor environments and potential hazards.

About CalOptima Health:

CalOptima is Orange County's largest health plan, committed to serving members with excellence and dignity. Our mission is to strengthen community health through compassionate leadership and professional dedication.

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