Grievance & Appeals Nurse, RN
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
RN handling California health-plan grievances, appeals, and quality-of-care cases for IEHP. Coordinating member care and regulatory reporting across providers and internal teams.
Responsibilities:
- Work directly with IPAs, hospitals, internal IEHP departments, and the Grievance team to process Grievance and Appeal cases according to policy, procedures, and regulatory requirements
- Coordinate member care within the scope of licensure with the member’s PCP, IPA, and/or IEHP Team Members
- Provide continuous quality-of-care support and assist in developing quality initiatives
- Serve as a resource for IEHP personnel, external practitioners, and providers
- Triage and assign Grievance and Appeals cases when designated, ensuring timeliness and regulatory compliance
- Support appropriate Grievance case categorization, including Quality of Care and member-harm identification
- Complete required internal reporting, including Critical Incidents and Potential Quality Incidents
- Complete mandatory external reporting, including CPS and APS
- Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
Requirements:
- Two (2) or more years of experience as an RN in case management, utilization management in managed care setting or related experience in a health care delivery setting required
- Two (2) or more years of experience as an RN in clinical nursing in a hands-on patient care delivery setting required
- Associate's Degree in Nursing from an accredited institution required
- Bachelor's Degree in Nursing from an accredited institution preferred
- Minimum possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California Board of Registered Nursing required
- Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS
- Knowledge of patient rights and ethical decision-making frameworks
- Knowledge of medical necessity and level of care, chronic disease and complex clinical cases
- Diagnostic and procedural understanding in a clinical setting
- Knowledge of regulatory guidelines surrounding grievances and appeals per CMS, DHHS, DMHC and NCQA
- Knowledge of member and provider legal rights to access the grievance and appeals resolution process
- Microcomputer applications: spreadsheet, database, and word processing
- Excellent interpersonal and communication skills
- Time management and priority setting skills
- Ability to incorporate LEAN principles into daily work
- Ability to work effectively with internal departments and external providers and entities
- Ability to assess complex Grievance & Appeal cases and recommend appropriate action
- Ability to analyze documentation of incoming cases
- Ability to effectively escalate issues following established protocols
- Word processing and data entry involving computer keyboard and screens
- Automobile travel within the Inland Empire
- Ability to occasionally lift or move up to 25 pounds
- Required vision abilities including close, distance, color, peripheral and depth perception, and ability to adjust focus
Benefits:
- Competitive salary
- CalPERS retirement
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
Similar Jobs
Registered Nurse, Utilization Management
Utilization Management RN reviewing medical necessity and admission status at UVA Health. Supporting payer authorization, regulatory compliance, and patient-centered outcomes.
Case Manager, Registered Nurse – Medicare
Remote Registered Nurse Case Manager coordinating Medicare members’ comprehensive care. CVS Health delivers connected, compassionate healthcare and wellness support.
Case Manager, Registered Nurse – Medicare
Remote Medicare Case Manager RN coordinating comprehensive member care, benefits, and wellness for CVS Health. Collaborating with members, providers, and community organizations to improve outcomes.
Pre-Authorization Nurse
Pre-Authorization Nurse coordinating military beneficiary care, quality reviews, transfers, and discharge planning for Humana’s healthcare services.
Care Coordinator, LPN
LPN coordinating remote kidney-care outreach, assessments, and documentation for Evergreen Nephrology’s value-based care programs. Supporting patients, providers, and care teams through chronic kidney disease management.
Patient Support Nurse
Patient Support Nurse guiding oncology patients and caregivers through treatment access and education. Supporting Valeris’ life sciences clients with phone-based patient support.
Medical Management Nurse, California
Medical Management Nurse reviewing complex inpatient cases for Elevance Health’s California HMO. Determining medical necessity, consulting Medical Directors, and supporting safe discharge planning.
Care Manager, Telephonic Registered Nurse
Telephonic RN care manager supporting Humana Medicare members with chronic conditions and transitional care needs. Coordinating personalized care plans, resources, and interventions to improve outcomes and independence.
Case Manager, Registered Nurse
Remote registered nurse case manager coordinating personalized care, utilization reviews, and hospital-to-home transitions. Supporting CVS Health’s connected, compassionate healthcare experience.
LPN – Licensed Practical Nurse, Quality Data Specialist
Licensed Practical Nurse auditing medical records and quality data for Geisinger, a nationally recognized healthcare provider. Supporting regulatory compliance, patient safety, and clinical excellence.
Advice Nurse, Behavioral Health
Virtual Mental Health Intake RN conducting psychiatric and chemical dependency intake screenings for Sutter Health. Providing crisis triage, mental status assessments, referrals, and patient placement remotely.
LPN Telephonic Nurse – Ophthalmology, Oncology
LPN providing telephonic patient support, education, referrals, and data collection for UBC’s pharmaceutical support programs. Serving patients, healthcare professionals, and consumers by phone.
Claims Review Nurse
Claims Review Nurse resolving healthcare claim disputes for Capitol Bridge’s Florida and multi-state medical review programs. Assessing documentation, coordinating clinical reviewers, and drafting determinations.
Triage Nurse, RN – Part Time
Remote part-time RN providing early-morning telephone triage for CareXM’s hospice and home health partners. Assessing patients, giving care instructions, coordinating care, and documenting in EHRs.
Registered Nurse, Reviewer
Registered Nurse reviewing Medicare records and preparing physician-review cases for Avar Consulting’s policy research programs. Supporting audits, quality assurance, and Medicare FFS/MA documentation.
Oncology Nurse Educator
Oncology Nurse Educator delivering clinical education for AstraZeneca’s lung and GI cancer medicines. Engaging healthcare providers across the Northwest and supporting patient care strategies.
Licensed Practical Nurse
Licensed Practical/Vocational Nurse delivering in-home care for Caring Hand Home Health Solutions. Providing treatment, education, documentation, and coordination for patients recovering at home.
Registered Nurse
Per-diem Registered Nurse supporting Caring Hand Home Health Solutions’ in-home patient recovery services. Reviewing OASIS assessments, ICD-10 coding, compliance, and clinical documentation quality.
Registered Nurse, Triage Call Agent
Registered Nurse triaging and educating patients by phone for Intermountain Health’s clinical communication center. Assessing needs, documenting calls, and directing patients to appropriate care.
Utilization Review Nurse – Weekends
Utilization Review RN managing evidence-based admission, stay, and discharge reviews at UAMS academic medical center. Coordinating payer communication and interdisciplinary discharge planning.