Grievance & Appeals Nurse Supervisor

Overview

The G&A Nurse Supervisor provides clinical and operational supervision to the Grievance &Appeals nursing team, including Nurse Specialists, Sr. Nurse Specialists, and State HearingRepresentatives. The Nurse Supervisor maintains an active clinical caseload while overseeing thedaily operations, workload distribution, and performance of the clinical team. The NurseSupervisor ensures that casework meets all regulatory and quality standards, including DHCSguidelines, CMS regulations, NCQA standards, and internal best practices. This positionsupports management in driving team performance, upholding productivity and accuracystandards, and ensuring a cohesive and collaborative team environment. The Nurse Supervisorexercises advanced clinical judgment to assess, guide, and resolve complex cases and providesdirect support and mentorship to staff. The role represents the department clinically in internaland external settings, including participation in hearings and key committees, and plays a centralrole in the department’s clinical oversight and continuous improvement initiatives.

Responsibilities

▪ Provides clinical and operational supervision to the Grievance and Appeals NurseSpecialists, Sr. Nurse Specialists, and State Hearing Representatives, includingmonitoring workload distribution, performance, and quality of casework.▪ Serves as the primary clinical lead for the department, representing G&A in crossfunctional committees, external meetings, and State Hearings as needed.▪ Oversees and supports the State Hearing Representatives by reviewing clinical content,preparing for hearings, and participating directly in hearings as needed.▪ Collaborates with management to assess team performance, identify areas for training,and implement clinical process improvements to enhance member experience andcompliance outcomes.▪ Conducts training and provides mentorship to nursing staff and clinical support for otherteam members, modeling best practices and ensuring adherence to policies andprocedures.▪ Identifies quality of care concerns, potential fraud, waste, and abuse, and escalatesappropriately to internal stakeholders or regulatory bodies.▪ Reviews and synthesizes complex medical records and clinical information (typically 30–500 pages per case) to prepare clinical summaries and inform resolution decisions.▪ Partners with G&A Case Analysts to ensure resolution letters are medically accurate andclinically appropriate, using member-friendly language.

▪ Ensures team adherence to DHCS, CMS, and NCQA requirements and contributes to the development and maintenance of clinical desktop procedures and audit readiness materials.▪ Participates in regular team and cross-departmental meetings, strategic planning sessions,and clinical review forums.▪ In coordination with the G&A Case Analyst, may contact members as it directly relatesto their immediate clinical concerns. May refer to Care Coordination forcontinued/ongoing case management.▪ Documents all casework activity thoroughly, accurately, timely, and ethically.▪ Provides back-up coverage for clinical staff as needed and serves as a subject matterexpert (SME) for both internal staff and external partners.▪ Other duties as assigned.

Qualifications

Education and Experience

Bachelor’s degree in Healthcare Administration, Business Bachelor’sdegree in Nursing, 3-5 years experience to include at least one (1) yearof case management experience and one (1) year in an acute caresetting; or equivalent combination of education and experience. CCMdesired. Knowledge of Partnership Grievance & Appeals processesdesired. General knowledge of managed care with emphasis in UM orCM preferred.

Special Skills, Licenses and Certifications

Current California Registered Nurse license required. Must be a criticalthinker and organized. Thorough knowledge of utilization and casemanagement programs and related criteria and protocols. Experience inmanaged care business practices and ability to access data informationusing computer systems. Ability to work within an interdisciplinarystructure and function independently in a fast-paced environment whilemanaging multiple priorities and meeting deadlines. Strongorganizational skills required. Effective telephone and computer dataentry skills required.

Performance Based Competencies

Excellent written and verbal communication skills with ability to readand interpret benefit contract specifications are required. Ability toapply clinical judgment to complex medical situations and make quickdecisions in a fast-paced environment. Works well under pressure andmaintains professional composure when interacting with allstakeholders, including members. Works independently, prioritizescase deliverables, remains customer-focused and stays current onchanges in the healthcare system that may trigger memberdissatisfaction. Can work in a team environment.

Work Environment And Physical Demands

Daily use of telephone and computer for most of the day. Standardcubicle workstation or telecommute eligible. When required, ability tomove, carry or lift objects weighing up to 25 lbs.

HIRING RANGE:

$136,296.78 - $177,185.82

All HealthPlan employees are expected to:▪ Provide the highest possible level of service to clients;▪ Promote teamwork and cooperative effort among employees;▪ Maintain safe practices; and▪ Abide by the HealthPlan’s policies and procedures, as they may from time to time beupdated.

IMPORTANT DISCLAIMER NOTICEThe job duties, elements, responsibilities, skills, functions, experience, educational factors andthe requirements and conditions listed in this job description are representative only and notexhaustive or definitive of the tasks that an employee may be required to perform. The employerreserves the right to revise this job description at any time and to require employees to performother tasks as circumstances or conditions of its business, competitive considerations, or workenvironment change.

Salary : $136,297 - $177,186