Remote Grievance & Appeals Nurse Specialist

CalOptima; Orange (CA); On-site; USD 91,000 - 145,000; Full time

Benefits offered by this job

Competitive compensation

Full Telework

Generous PTO program

CalPERS pension program and retirement

Tuition Reimbursement

Professional development opportunities

Flexible scheduling

Comprehensive benefits package

Job summary

CalOptima Health seeks a Grievance & Appeals Nurse Specialist to join our mission-driven team. You will conduct clinical reviews, support member concerns, and coordinate with providers and stakeholders to ensure timely, compliant decisions.

This full telework role in California requires CA RN or LVN licensure and 5 years of healthcare/managed care experience, plus strong communication, analysis, and multi-project leadership to help improve access to care.

Qualifications

• High school diploma required; 5 years health care/managed care experience preferred.
• CA RN license or LVN license required.
• Ability to telework within California and occasional office attendance.

Responsibilities

• Participates in mission-driven culture with a member focus on service, dignity and accountability.
• Prepares clinical reviews based on guidelines and monitors cases.
• Ensures regulatory timelines are met and presents recommendations to physicians.
• Resolves complex member issues within established timelines.
• Maintains accurate case records and analyzes cases for reporting.
• Oversees state hearing cases and coordinates with providers during appeals.

Skills

Communication skills

Bilingual English + threshold language

Independent working

Flexibility & scheduling

Analytical thinking

Project management

Multitasking

MS Office proficiency

Education

High school diploma

Tools

Microsoft Office (Word, Excel, Outlook, PowerPoint)

GARS/State hearing processes software

Job description

CalOptima Health seeks a Grievance & Appeals Nurse Specialist to join our mission-driven team. You will conduct clinical reviews, support member concerns, and coordinate with providers and stakeholders to ensure timely, compliant decisions.

This full telework role in California requires CA RN or LVN licensure and 5 years of healthcare/managed care experience, plus strong communication, analysis, and multi-project leadership to help improve access to care.