Clinical Appeals Nurse - RN

Are you a licensed nurse with a strong clinical background and a passion for patient advocacy? We’re looking for a Clinical Appeals Nurse Specialist to join our team. If you thrive in a fast-paced, regulatory-driven environment and love championing patient rights, this could be a perfect fit!

What You’ll Do:

• Conduct clinical reviews and ensure compliance with state and federal regulations.
• Present recommendations to physician reviewers for final decisions.
• Manage state hearing cases and prepare compelling case narratives.
• Communicate medical decisions with members and providers.
• Accurately document case actions in the Grievance & Appeals database.
• Represent CalOptima Health at state hearings and advocate for fair outcomes.
  
  
  

All You Need:

• Active RN license in California (LVN will be considered)
• 5 years of healthcare/managed care experience (Grievances & Appeals, UM, or Quality Management a plus!)
• Strong regulatory knowledge and ability to analyze clinical cases.
• Proficiency in Microsoft Office (Word, Outlook, Excel, PowerPoint).
• Bilingual skills in English and either Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese a plus!
  
  
  

Job Details:

• Department: Grievance & Appeals
• Location: Onsite | Orange, CA
• Schedule: Monday – Friday, 8:00 AM – 5:00 PM
• Pay: $43.66 – $69.86/hr. (DOE)
  
  
  

This is a great opportunity to get a foot in the door with a respected organization. If you’re ready to use your clinical expertise to make a difference while working in a supportive and mission-driven team, we’d love to hear from you!

Apply today! Let’s chat about this exciting opportunity.

EEO/AA Employer/Vet/Disabled.

The Know Your Rights poster is available here:

https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here:

https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_ English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

ALL's WELL participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.

https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

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