Grievance Appeals Nurse (LVN)

divh2Temporary Grievance Appeals Nurse/h2pThe position is 100% remote, and the candidates must reside in Southern California. The Temporary Grievance Appeals Nurse is responsible for managing and coordinating grievance and appeal cases in compliance with policies and state and federal regulatory requirements, including CMS, DHCS, DMHC, and NCQA standards. This role partners closely with IPAs, hospitals, providers, and internal departments to ensure timely resolution of cases, appropriate care coordination, and delivery of high-quality member outcomes. The nurse also serves as a clinical subject matter expert, providing guidance on grievance processes, regulatory compliance, and quality improvement initiatives./ph3What You Will Do:/h3ulliManage and process grievance and appeal cases in compliance with regulatory and internal guidelines/liliCoordinate care with PCPs, IPAs, providers, and internal teams to ensure continuity of care/liliReview and investigate member grievances, including Quality of Care and Non-Quality of Care cases/liliProvide clinical oversight, including final nurse review and case evaluation/liliTriage and assign new cases based on medical urgency and regulatory timelines/liliServe as a liaison between departments including Member Services, Provider Services, Compliance, and Medical Services/liliGenerate professional written correspondence to members, providers, and regulatory entities/liliConduct quality assurance reviews for accuracy in case classification, documentation, and timeliness/liliAudit reports to ensure all cases are captured and processed within required timeframes/liliIdentify trends, escalate issues, and support development of quality improvement initiatives/liliPrepare recommendations on appeals and submit to Medical Director for review/liliSupport grievance committee reviews and maintain all required documentation/liliEnsure compliance with mandated reporting requirements, including abuse reporting/liliAct as a clinical resource for internal teams and external partners/li/ulh3You Will Be Successful If:/h3ulliStrong knowledge of grievance and appeals regulations within a managed care environment/liliDemonstrated clinical judgment and critical thinking in case review and resolution/liliAbility to manage multiple cases while meeting strict regulatory timelines/liliEffective communication skills when working with members, providers, and cross-functional teams/liliHigh level of accuracy and attention to detail in documentation and reporting/liliProactive approach to identifying trends, issues, and opportunities for improvement/liliAbility to work efficiently in a fast-paced, team-oriented, remote environment/li/ulh3What You Will Bring:/h3ulliActive, unrestricted, and unencumbered California LVN license required/liliHigh school diploma or GED required; Associates degree preferred/lili2+ years of case management, utilization management, or managed care experience/liliExperience in an HMO or managed care environment preferred/liliValid California Drivers License required/liliWorking knowledge of CMS, DHCS, DMHC, and NCQA regulations/liliUnderstanding of member and provider rights within grievance and appeals processes/liliFamiliarity with external agencies such as CCS, CMS, DMHC, and DHCS/liliProficiency in Microsoft Office applications (Word, Excel, databases)/liliStrong written and verbal communication skills/liliDemonstrated critical thinking and problem-solving ability/liliStrong organizational skills with attention to detail and ability to meet deadlines/liliAbility to escalate issues appropriately and follow established protocols/liliTeam-oriented mindset with a positive, professional attitude/li/ulpImpresiv Health is a healthcare consulting partner specializing in clinical operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges./ppOur approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it./ppThats Impresiv!/p/div