Grievance & Appeals RN/LPN

22nd Century Technologies, Inc.
Pay rate: $69.86/hrs. on w2
United States, California, Orange
Jul 02, 2025
Job Title: Grievance & Appeals RN/LPN Location: 505 City Parkway West Orange CA 92868 Duration: 6+months Job Mode: On-Site Pay rate: $69.86/hrs. on w2 without benefits Shift hours: Monday to Friday (8:00 a.m. - 5:00 p.m.) Job Description: 80% - Program Support: Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions. Presents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination. Resolves complex and sensitive member issues within established timelines. Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases. Analyzes and reports cases through GARS' subcommittee. Assists with the notification process to members or providers on the clinical decision issued.. Assists members in coordinating their services with providers and communicates the status and outcome to members. 15% - Administrative Support: Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Participates in departmental meetings, trainings and audits as requested. 5% - Completes other projects and duties as assigned. Minimum Qualifications: High School diploma required PLUS 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 may also be qualifying. Preferred Qualifications: Current unrestricted 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, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese). Required Licensure / Certifications: Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California. 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. 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.