Temporary Grievance & Appeals Nurse (LVN)

Manages and resolves member grievance and appeal cases in compliance with state/federal regulations (DMHC, DHCS, CMS, NCQA), collaborating with providers, IPAs, hospitals, and internal teams to ensure timely, accurate resolutions while serving as clinical subject matter expert.

Key Responsibilities

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Process grievance/appeals cases within regulatory timelines, conducting thorough investigations and coordinating care with PCPs, providers, IPAs, Member Services, Provider Services, Compliance, and Medical Services.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Perform clinical oversight including final nurse review of Non-Quality-of-Care cases, initial medical reviews, Quality-of-Care investigations for Medical Director, triage for urgency/Organizational Determinations, and QA audits.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Generate professional correspondence to members/providers/regulators, prepare appeal recommendations for Medical Directors, and ready files for Grievance Committee review.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Identify trends/systemic issues, complete mandated reporting (abuse allegations), audit daily reports, assign cases appropriately, and escalate quality improvement opportunities.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Maintain documentation per regulatory standards, resolve medical/quality-of-care grievances, and apply LEAN principles for process efficiency.
  
  

Minimum Qualifications

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> High school diploma or GED required; Associate's degree from accredited institution preferred.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> 2 years case management, utilization management, or related experience in managed care/healthcare delivery.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> HMO/managed care experience preferred.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Active, unrestricted California LVN license required.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Valid driver's license.
  
  

Key Skills

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Expert knowledge of CMS/DHCS/DMHC/NCQA regulations, grievance/appeal rights, and managed care processes.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Proficiency in Microsoft Word, Excel, database systems.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Strong critical thinking, attention to detail, deadline management, communication, and team collaboration.
  
  

Work Arrangement

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Approved for telecommute with occasional in-person attendance required.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Local automobile travel may be needed.
  
  

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