Grievance & Appeals Nurse

IEHP

. Implement management of grievance and appeals cases in compliance with state and federal guidelines .

Posted 11/9/2026full-timeCalifornia • United StatesJuniorMid-Level💰 $63,898 - $83,075 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in grievance and appeals case management, ensuring compliance with state and federal guidelines while effectively collaborating with various departments. Proficient in conducting investigations, maintaining documentation, and providing clinical oversight to support quality initiatives and continuity of care.

Highest-signal resume keywords

Grievance And Appeals Case ManagementVocational Nurse (LVN) LicenseRegulatory Compliance KnowledgeCritical Thinking And Problem-SolvingExcellent Written And Verbal Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ManagementUtilization ManagementMedical ReviewQuality Assurance ReviewsDocumentation MaintenanceData AnalysisGrievance Resolution ProcessTriage And PrioritizationRegulatory Guidelines KnowledgeLEARN Principles Implementation

Soft Skills

Attention To DetailTeam CollaborationPositive AttitudeAbility To Escalate IssuesTime Management

Tools & Technologies

Spreadsheet ApplicationsDatabase ApplicationsWord Processing Applications

Certifications & Qualifications

Vocational Nurse (LVN) LicenseCalifornia Driver's License

Industry Keywords

Managed CareHMOCMSDHCSDMHCNCQAMember ServicesProvider ServicesComplianceHealth Care Delivery

About the role

Key responsibilities & impact

Implement management of grievance and appeals cases in compliance with state and federal guidelines
Process grievance and appeals cases thoroughly and timely according to IEHP policies and regulatory guidelines
Investigate member grievance issues and coordinate care appropriately
Collaborate with Grievance and Appeals, Member Services, Provider Services, Compliance, Medical Services, and regulatory departments
Review case coding, resolve medical issues, and coordinate care with practitioners, providers, and agencies
Resolve medical grievances with IEHP staff, Grievance Management, and providers
Identify case issues, develop quality initiatives, make outside-agency referrals, and escalate system issues
Interpret departmental policies, procedures, regulations, benefits, and processes for IEHP members
Serve as a subject matter expert and resource for clinical and non-clinical team members
Maintain grievance and appeals documentation according to external agency requirements
Monitor trends involving contracted practitioners and providers to support continuity of care
Provide clinical oversight and final nurse review of assigned grievance and appeals cases
Perform initial medical review and ensure follow-up is completed by designated MedHOK business partners
Generate written correspondence to providers, members, and regulatory entities
Triage new cases for medical urgency and potential Organizational Determination
Complete quality assurance reviews for classification, categorization, documentation, and priority
Audit daily reports and maintain case logs within regulatory timeframes
Assign new cases to appropriate teams when designated
Report allegations of physical and sexual abuse to appropriate authorities
Prepare recommendations to uphold or deny appeals and forward them to the Medical Director
Prepare files for Grievance and Appeals Committee reviews
Perform other duties supporting health plan operations and department business needs

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 outside agencies and resources such as CCS, CMS, DMHC, or DHCS
Knowledge of regulatory guidelines surrounding grievances and appeals per CMS, DHCS, DMHC, and NCQA
Proficiency with spreadsheet, database, and word processing applications
Excellent written and verbal communication skills
Proven critical thinking and strong problem-solving capability
Commitment to incorporating LEAN principles into daily work
Strong attention to detail
Ability to prioritize work and meet project deadlines
Ability to effectively escalate issues following established protocols
Positive attitude and 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