- Job Title: Grievance and Appeals Nurse Specialist
- CalOptima Health is seeking a highly motivated an experienced TEMP - Grievance & Appeals Nurse Specialist to join our team.
- The Grievance and Appeals Nurse Specialist participates in managing CalOptima Healths medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.
- The incumbent will clearly articulate the facts and CalOptima Healths position regarding disputes to the Administrative Law Judge hearing the case.
- Presents recommendations based on clinical review, criteria and organizational policies to CalOptima Healths physician reviewers for final determination.
- Assigns position statements and represents CalOptima Health at state hearings.
- Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
- Active Licensed Vocational Nurse (LVN) license to practice in the state of California required.
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