California Licensed Grievance Nurse

Job Summary

To support the Grievance and Appeals team, the remote California Licensed Grievance Nurse will manage grievance and appeal cases in accordance with regulatory guidelines, coordinate care with healthcare providers, and serve as a resource for internal and external stakeholders.

Key responsibilities

• Process grievance and appeal cases per established policies and regulatory requirements
• Coordinate care with members' primary care providers and internal teams to ensure quality of care
• Triage and assign grievance and appeal cases to meet timeliness and compliance standards

Required qualifications

• Active, unrestricted Registered Nurse (RN) license issued by the California Board of Registered Nursing
• Two or more years of experience as an RN in case management or utilization management in a managed care setting
• Two or more years of clinical nursing experience in a hands-on patient care delivery setting
• Associate's Degree in Nursing from an accredited institution; Bachelor's Degree preferred
• Knowledge of regulatory guidelines regarding grievances and appeals from agencies such as CMS and DMHC