Grievance & Appeals Nurse Specialist

About the role

We are seeking a Grievance & Appeals Nurse Specialist to join our mission-driven community-based organization, CalOptima. This position is approved for full telework within the State of California, with at least two (2) days per week in the main office in Orange, CA.

Responsibilities

• Manage CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.
• Ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards, and policies and procedures.
• 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.
• Clearly articulate the facts and CalOptima Health's position regarding disputes to the Administrative Law Judge hearing the case.
• Create and review resolution letters for appropriateness of clinical criteria and regulatory requirements.
• Participate in program support, preparing clinical reviews based on clinical guidelines and providing monitoring of cases involving medical decisions and quality of care or service decisions.
• Resolve complex and sensitive member issues within established timelines.
• Maintain departmental database and ensure the integrity of records by accurately entering case actions to assigned cases.
• Analyze and report cases through GARS' subcommittee.
• Oversee state hearing cases.
• Absorb notifications to members or providers on the clinical decision issued.
• Discuss the appeal process, medical decisions, and hearing rights with members.
• Coordinate services with providers and communicate the status and outcome to members.
• Assign position statements and represent CalOptima Health at state hearings.

Requirements

• High school diploma required plus 5 years of health care/managed care experience required, preferably in grievances and appeals, utilization management, and/or quality management; an equivalent combination of education and experience may also be qualifying.
• Current unrestricted Registered Nurse (RN) license to practice in the state of California.
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).
• Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.

Qualifications

• Develop rapport and establish 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.
• 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

• 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.

Benefits

• Competitive compensation
• CalPERS pension program and additional retirement packages
• Comprehensive benefits package
• Tuition reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• Quality work-life balance
• Variety of wellness programs