Grievance & Appeals Nurse

Description:
The Grievance & Appeals Nurse is responsible for managing and coordinating member grievance and appeal cases to ensure compliance with IEHP policies, regulatory requirements, and quality standards. This role partners closely with internal departments, providers, hospitals, and external agencies to investigate, resolve, and document grievance and appeal cases while supporting continuity of care and member advocacy. The Grievance & Appeals Nurse serves as a clinical resource and subject matter expert for grievance and appeals processes, ensuring timely resolution, regulatory compliance, and quality outcomes for IEHP members.

What You Will Do:

• Manage grievance and appeal cases in compliance with CMS, DHCS, DMHC, NCQA, and IEHP regulatory standards.
• Coordinate with providers, hospitals, IPAs, and internal departments to investigate and resolve member grievances and appeals.
• Conduct clinical reviews and provide oversight for non-quality and quality-of-care grievance cases.
• Review case coding, classification, documentation, and prioritization to ensure accuracy and regulatory compliance.
• Triage incoming grievance and appeal cases to identify medical urgency and escalation needs.
• Prepare recommendations for appeal determinations and collaborate with Medical Directors for final approvals.
• Maintain complete and accurate grievance and appeals documentation and reporting.
• Support quality improvement initiatives by identifying trends, system issues, and opportunities for process enhancement.
• Serve as a subject matter expert and resource for clinical and non-clinical team members regarding grievance and appeals processes.
• Generate professional written correspondence to members, providers, and regulatory agencies using approved templates.
• Participate in audits, quality assurance reviews, and committee preparation activities.
• Ensure timely case assignment, follow-up, and adherence to departmental workflows and regulatory turnaround times.

You Will Be Successful If:

• Strong knowledge of grievance and appeals regulations within managed care, including CMS, DHCS, DMHC, and NCQA requirements.
• Exceptional critical thinking, problem-solving, and clinical judgment skills.
• Ability to effectively prioritize competing deadlines while maintaining accuracy and compliance.
• Strong attention to detail with excellent organizational and documentation skills.
• Excellent verbal and written communication abilities.
• Collaborative mindset with the ability to work across multidisciplinary teams while maintaining a member-focused approach.
• Proven ability to identify trends, appropriately escalate issues, and support quality improvement initiatives.
• Comfortable working in a fast-paced managed care environment with evolving regulations and processes.
• Professionalism, accountability, and commitment to continuous improvement.

What You Will Bring:

• Active, unrestricted, and unencumbered California LVN license required.
• High school diploma or GED required; Associate’s degree preferred.
• Minimum of two (2) years of case management, utilization management, managed care, or related healthcare experience required.
• HMO or managed care experience preferred.
• Knowledge of grievance and appeals processes, regulatory guidelines, and member/provider rights.
• Familiarity with agencies such as CMS, DHCS, DMHC, and CCS.
• Proficiency with Microsoft Office applications including Word, Excel, and database systems.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality and professionalism when handling sensitive member information.
• Valid California Driver’s License preferred.

About Impresiv Health:

Impresiv 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.

Our 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.

That’s Impresiv!