: X TEMP - Grievance & Appeals Nurse Specialist - 278
Apply NowCompany: CA_CalOptima_Grievance & Appeals
Location: Orange, CA 92867
Description:
Details
Client Name
CA_CalOptima_Grievance & Appeals
Job Type
Travel
Offering
Nursing
Profession
Healthcare Professional (Nursing)
Specialty
Clinical Nurse Specialist
Job ID
16176946
Job Title
: X TEMP - Grievance & Appeals Nurse Specialist - 278
Weekly Pay
$2180.0
Shift Details
Shift
08:00 AM - 05:00 PM
Scheduled Hours
40
Job Order Details
Start Date
03/12/2025
End Date
06/11/2025
Duration
13 Week(s)
Job Description
Due Date - 03/14/2025
Submission Information:
The deadline to be guaranteed full review of your submission is due by Friday, March 14, 2025 by 9:00 p.m. PST. This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.
Duties & Responsibilities:
80% - Program Support
oParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
oPrepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
oEnsures all cases are completed in accordance with state and federal regulatory requirements including timelines.
oPresents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination.
oResolves complex and sensitive member issues within established timelines.
oMaintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
oAnalyzes and reports cases through GARS' subcommittee.
oOversees state hearing cases.
oDiscusses appeal process, medical decisions and hearing rights with members.
oAssists members in coordinating their services with providers and communicates the status and outcome to members.
oAssigns position statements and represents CalOptima Health at state hearings.
15% - Administrative Support
oParticipates in departmental meetings, trainings and audits as requested.
oAssists with the notification process to members or providers on the clinical decision issued.
5% - Completes other projects and duties as assigned.
Minimum Qualifications:
High School diploma required.
5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and/or Quality Management.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
Active Registered Nurse (RN) license to practice in the state of California.
Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities:
Develop rapport and establish and maintain 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.
Work in a fast-paced environment and in an efficient manner.
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 (With or Without Accommodations):
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
Work Environment:
If located at the 500, 505 Building or a remote work location:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.
If located at PACE:
Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
If located in the Community:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
Client Details
Address
505 City Parkway West
City
Orange
State
CA
Zip Code
92868
Client Name
CA_CalOptima_Grievance & Appeals
Job Type
Travel
Offering
Nursing
Profession
Healthcare Professional (Nursing)
Specialty
Clinical Nurse Specialist
Job ID
16176946
Job Title
: X TEMP - Grievance & Appeals Nurse Specialist - 278
Weekly Pay
$2180.0
Shift Details
Shift
08:00 AM - 05:00 PM
Scheduled Hours
40
Job Order Details
Start Date
03/12/2025
End Date
06/11/2025
Duration
13 Week(s)
Job Description
Due Date - 03/14/2025
Submission Information:
The deadline to be guaranteed full review of your submission is due by Friday, March 14, 2025 by 9:00 p.m. PST. This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.
Duties & Responsibilities:
80% - Program Support
oParticipates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
oPrepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.
oEnsures all cases are completed in accordance with state and federal regulatory requirements including timelines.
oPresents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination.
oResolves complex and sensitive member issues within established timelines.
oMaintains departmental database and the integrity of records by accurately entering case actions to assigned cases.
oAnalyzes and reports cases through GARS' subcommittee.
oOversees state hearing cases.
oDiscusses appeal process, medical decisions and hearing rights with members.
oAssists members in coordinating their services with providers and communicates the status and outcome to members.
oAssigns position statements and represents CalOptima Health at state hearings.
15% - Administrative Support
oParticipates in departmental meetings, trainings and audits as requested.
oAssists with the notification process to members or providers on the clinical decision issued.
5% - Completes other projects and duties as assigned.
Minimum Qualifications:
High School diploma required.
5 years of health care/managed care experience required. Preferably in the following related areas of responsibility: Grievances and Appeals, Utilization Management and/or Quality Management.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
Active Registered Nurse (RN) license to practice in the state of California.
Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.
Knowledge & Abilities:
Develop rapport and establish and maintain 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.
Work in a fast-paced environment and in an efficient manner.
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 (With or Without Accommodations):
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
Work Environment:
If located at the 500, 505 Building or a remote work location:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.
If located at PACE:
Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
If located in the Community:
Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.
Client Details
Address
505 City Parkway West
City
Orange
State
CA
Zip Code
92868