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Job Title: Temporary – Grievance & Appeals Nurse Specialist
Department: Grievance & Appeals
Work Arrangement: Onsite (Full Office)
Schedule: Monday – Friday | 8:00 a.m. – 5:00 p.m.
About the Role:
CalOptima Health is seeking a Grievance & Appeals Nurse Specialist (Temporary) to join our team. In this role, you will manage medical appeals and state hearing reviews across all lines of business, ensuring compliance with regulatory standards and organizational policies. You will investigate appeals, prepare clinical case narratives, and represent CalOptima Health’s position in state hearings. This position plays a vital role in supporting fair and timely resolution of member and provider disputes.
Responsibilities:
Process expedited and standard medical appeal and state hearing requests in compliance with regulations and policies.
Investigate and prepare case narratives and statements of position based on clinical data, benefits, and applicable regulations.
Clearly present case facts and CalOptima Health’s position during Administrative Law Judge hearings.
Draft and review resolution letters to ensure compliance with clinical and regulatory standards.
Collaborate with internal teams to ensure timely, accurate, and fair resolution of appeals and grievances.
Minimum Qualifications:
High School diploma required.
5 years of healthcare or managed care experience, preferably in grievances and appeals, utilization management, and/or quality management.
Equivalent combinations of education and experience may be considered.
Current unrestricted Licensed Vocational Nurse (LVN) license in California.
Preferred Qualifications:
Current unrestricted Registered Nurse (RN) license in California.
Bilingual in English and one of CalOptima Health’s threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).
Knowledge & Abilities:
Strong communication skills (oral and written) with ability to present complex information clearly.
Build and maintain positive relationships with staff, leadership, and external stakeholders.
Effective organizational, analytical, and problem-solving skills.
Ability to work independently in a fast-paced environment and manage multiple priorities.
Proficiency with Microsoft Office (Word, Outlook, Excel, PowerPoint) and relevant job-specific systems.
Flexibility to participate in occasional evening or weekend events.
Why Join Us:
At CalOptima Health, you’ll have the opportunity to make an impact by ensuring members and providers receive fair, timely, and compliant grievance and appeals support, while working in a collaborative and mission-driven environment.
Best regards,
Ashu Chaudhary
Senior Healthcare Recruiter
Aroha Technologies
Ashu@arohatechnologies.com| 510-455-4427