Grievance & Appeals Nurse

IEHP

. Work directly with IPAs, hospitals, internal IEHP departments, and the grievance team .

Posted 11/10/2026full-timeRemote • California • United StatesJuniorMid-Level💰 $63,898 - $83,075 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in case management and utilization management within a managed care setting, ensuring compliance with regulatory requirements and quality initiatives. Proficient in coordinating member care and resolving grievances while maintaining strong communication and problem-solving skills.

Highest-signal resume keywords

Case Management ExperienceUtilization Management ExperienceVocational Nurse (LVN) LicenseKnowledge of DHCS, DMHC, CMS, and NCQA RequirementsProficiency with Spreadsheet, Database, and Word Processing Applications

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ManagementUtilization ManagementGrievance Policy & ProceduresQuality Initiatives DevelopmentRegulatory ComplianceHEDIS KnowledgeCAHPS KnowledgeCritical ThinkingProblem-SolvingLEAN Principles

Soft Skills

Excellent Written CommunicationExcellent Verbal CommunicationAttention to DetailTeam CollaborationAbility to Prioritize Work

Certifications & Qualifications

Vocational Nurse (LVN) LicenseHigh School Diploma or GED

Industry Keywords

Managed CareHMOGrievance and Appeals Resolution ProcessMember and Provider Legal RightsIEHP Quality ProgramCalifornia Driver's License

About the role

Key responsibilities & impact

Work directly with IPAs, hospitals, internal IEHP departments, and the grievance team
Ensure grievance and appeal cases are processed according to Grievance Policy & Procedures and DMHC, DHCS, CMS, and NCQA requirements
Coordinate Member care with the Member’s PCP, IPA, and IEHP team members to provide continuous quality care
Assist in developing quality initiatives
Serve as a resource for IEHP personnel, external practitioners, and providers
Triage and assign grievance and appeal cases when designated
Ensure case timeliness and regulatory requirements are met
Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation

Requirements

What you’ll need

Two (2) years or more case management, utilization management in managed care setting or related experience in a health care delivery setting
Experience in an HMO or experience in managed care setting preferred
High school diploma or GED required
Associate’s degree from an accredited institution preferred
Minimum possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required
Must have a valid California Driver's License
Working knowledge and understanding of Member and Provider legal rights to access the grievance and appeals resolution process
Knowledge of DHCS, DMHC, CMS, IEHP, and NCQA requirements and regulatory guidelines
Knowledge of outside agencies and resources such as CCS, CMS, DMHC, or DHCS
Proficiency with spreadsheet, database, and word processing applications
Excellent written and verbal communication skills
Critical thinking and strong problem-solving capability
Commitment to incorporating LEAN principles into daily work
Strong attention to detail
Ability to prioritize work and adhere to project deadlines
Ability to escalate issues following established protocols
Ability to work in a team setting

Benefits

Comp & perks

Competitive salary
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance