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Grievance &amp; Appeals Nurse Specialist CalOptima Join Us in this Amazing Opportunity The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Grievance &amp; Appeals Nurse Specialist and help shape the future of healthcare where you'll be an integral part of our Grievance &amp; Appeals team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework. 
<ul>
<li> If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. </li>
</ul>
 You will participate in managing CalOptima Health's medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests. You will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards and policies and procedures. You will investigate and prepare case narratives and statements of position based on clinical information, benefits and applicable regulations related to member or provider disputes of decisions. You will clearly articulate the facts and CalOptima Health's position regarding disputes to the Administrative Law Judge hearing the case. You will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: 
<ul>
<li>80% - Program Support
<ul>
<li>Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions.</li>
<li>Ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.</li>
<li>Presents recommendations based on clinical review, criteria and organizational policies to CalOptima Health's physician reviewers for final determination.</li>
<li>Resolves complex and sensitive member issues within established timelines.</li>
<li>Maintains departmental database and the integrity of records by accurately entering case actions to assigned cases.</li>
<li>Analyzes and reports cases through GARS' subcommittee.</li>
<li>Oversees state hearing cases.</li>
<li>Assists with the notification process to members or providers on the clinical decision issued.</li>
<li>Discusses appeal process, medical decisions and hearing rights with members.</li>
<li>Assists members in coordinating their services with providers and communicates the status and outcome to members.</li>
<li>Assigns position statements and represents CalOptima Health at state hearings. </li>
</ul>
</li>
<li>15% - Administrative Support
<ul>
<li>Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.</li>
<li>Participates in departmental meetings, trainings and audits as requested. </li>
</ul>
</li>
<li>5% - Completes other projects and duties as assigned. </li>
</ul>
 Do You Have What the Role Requires? 
<ul>
<li>High school diploma required PLUS 5 years of health care/managed care experience required, preferably in the following related areas of responsibility: grievances and appeals, utilization management and/or quality management; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.</li>
</ul>
 You'll Stand Out More If You Possess the Following: 
<ul>
<li>Current unrestricted Registered Nurse (RN) license to practice in the state of California. </li>
<li>Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).</li>
</ul>
 What the Regulatory Agencies Need You to Possess? 
<ul>
<li>Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.</li>
</ul>
 Your Knowledge &amp; Abilities to Bring to this Role: 
<ul>
<li>Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.</li>
</ul>
 Your Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Ways We Are Here For You 
<ul>
<li>You'll enjoy competitive compensation for this role.
<ul>
<li>Our current hiring range is: Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615). 
<ul>
<li>The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors. </li>
</ul>
</li>
</ul>
</li>
<li>This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**) </li>
<li>A <a href="https://apptrkr.com/get_redirect.php?id=6827312&amp;targetURL=https://www.caloptima.org/en/careers#benefits" target="_blank">comprehensive benefits package</a> </li>
<li>CalPERS pension program and additional retirement packages. </li>
<li>Additional benefits and perks including:
<ul>
<li>A generous PTO program</li>
<li>A quality work life balance</li>
<li>Various wellness programs</li>
<li>Tuition Reimbursement</li>
<li>Professional development opportunities</li>
<li>Career development opportunities</li>
<li>Flexible scheduling</li>
<li>And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.</li>
</ul>
</li>
</ul>
 Our Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is January 13, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. To apply, please visit: <a href="https://apptrkr.com/6827312" target="_blank">https://jobs.caloptima.org/jobs/grievance-appeals-nurse-specialist-505-city-parkway-west-california-united-states-15e815c2-3fcd-4db0-a51e-8078f72ffc27</a> Copyright 2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-6b482c6ee7f7164a8ac6b7e408651c04

Grievance & Appeals Nurse Specialist

Graham Ricker Air Conditioning &amp; Heating is a family-owned and operated HVAC company based in Cathedral City California that has been in business serving the Coachella Valley since 1988. We are seeking a professional and organized Office Manager to join our team. This is a Part Time position which involves front desk operations, providing exceptional customer service, and supporting office management tasks. The ideal candidate will have strong computer literacy, excellent communication skills, and experience in administrative or clerical roles. Bilingual abilities are a plus to effectively serve diverse clients and team members. This position offers an opportunity to work in a dynamic environment where organizational skills and attention to detail are highly valued.
 Responsibilities Interact with prospective clients and existing clients in a friendly and professional manner as the representative of the company. Manage phone systems, screen calls, and direct inquiries appropriately. Schedule appointments, manage calendars, and coordinate meetings using HubSpot, Google Workspace and Microsoft Office tools. Perform data entry, filing, and maintain accurate records using QuickBooks and HubSpot. Support office management tasks such as supply ordering, filing systems, and general administrative duties. Assist with bookkeeping tasks including basic bookkeeping and invoicing as needed. Provide excellent customer support via phone, email, or in person, demonstrating proper phone etiquette. Skills - Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and Google Workspace applications - Experience with QuickBooks - Strong organizational skills with the ability to prioritize tasks effectively - Good typing accuracy for data entry and document preparation - Exceptional communication skills, both verbal and written; bilingual abilities are advantageous - Office management experience including filing, proofreading, and calendar management - Ability to handle customer service interactions with professionalism and patience - Strong time management skills to balance multiple responsibilities efficiently - Previous experience as a service industry Office Manager is desirable but not required
Compensation: Starting at $17 per hour for 3 to 4 days per week.

Office Manager

OUR STATEMENT The San José State University Research Foundation (SJSURF) is committed to building a work environment where everyone can show up as their own self and have an opportunity to contribute, develop, and advance in their career. Diversity, Equity, and Inclusion (DEI) are core values of the organization. We strive to attract, retain, and develop employees who reflect the community and society where we work and live. The Research Foundation aims to develop a culture where everyone feels welcome, shares their views, and where differences in backgrounds and perspectives are seen as adding value. GENERAL NATURE OF POSITION
The administrative assistant delivers support services to selected San José State University students. Responsible for recordkeeping, database, and budget management, as well as other administrative support duties as needed. &nbsp;Additionally, this person will report directly to the ASPIRE/McNair Scholars program director. &nbsp;
ESSENTIAL DUTIES &amp; RESPONSIBILITIES
<ol>
<li>Establishes and maintains a complex computerized system of files and records involving participant eligibility, demographic data, results of outcome objectives, and project contracts. Prepares written and statistical reports on student progress and outcomes as requested by the program director.</li>
<li>Maintains expenditure records by specific budget category. Creates and maintains computerized spreadsheets for budget monitoring and control. Reviews and verifies all computer printouts on program budget status prepared by SJSU Research Foundation accounting office.</li>
<li>Prepares quarterly budget reports and projected budget reports for the program director to monitor spending and the effective use of funds.</li>
<li>Assists the director in managing the program budgets and ensuring compliance with TRiO legislation and regulations as stated by the Department of Education.</li>
<li>Assists the director to ensure compliance in accordance with the grant contract with the U.S. Department of Education and SJSU Research Foundation policies and procedures.&nbsp;</li>
<li>Onboarding student staff and monitoring their daily tasks.</li>
<li>Clerical duties as assigned.</li>
<li>Coordinates office workflow and maintenance of files and records between ASPIRE and the McNair Scholars Programs.</li>
<li>Advises the director of any problem areas in handling office workflow, questions about program priorities, and suggestions for improving the efficient operation of the program office.</li>
<li>Arrange and coordinate travel and travel reimbursement for staff and participants of ASPIRE and McNair Programs.</li>
<li>Other duties as assigned.</li>
</ol>
&nbsp;
INTERPERSONAL CONTACTS
<ol>
<li>Reports to the director ASPIRE/McNair</li>
</ol>
&nbsp;
SUPERVISORY RESPONSIBILITIES
Minimal. Provides training to student aids that work for ASPIRE and the McNair Scholars Programs. Assists with student’s time management and schedules. &nbsp;
QUALIFICATIONS Education and Experience
<ul>
<li>Requires a minimum of an A.A. degree or equivalent. BA/S preferred.</li>
<li>Minimum of 4-6 years related experience.</li>
<li>Preferably with an accounting background or strong knowledge of handling various budgets.</li>
<li>TRIO experience preferred.</li>
</ul>
 Knowledge, Skills, and Abilities Required
<ul>
<li>Excellent written and verbal communication skills.</li>
<li>Ability to work independently in a culturally diverse setting.</li>
<li>PC experience including working knowledge of word processing, excel, and proficiency in interpreting database reporting and database management, bookkeeping and accounting.</li>
<li>Knowledge of office methods and procedures, particularly the handling of confidential student and personnel records.</li>
<li>Ability to maintain an efficient front operation with a strong service orientation to students.</li>
</ul>
 Physical Requirements
<ul>
<li>Works in standard office environment with desk, telephone, computer, bookshelves and file cabinets provided. Maintains office copier and fax machine.</li>
</ul>
 Complexity of Duties
<ul>
<li>Works with minimal direction on all assigned projects.</li>
<li>Exercises independent judgment in developing effective and productive office workflow.</li>
<li>Works independently in maintaining both electronic and hard copy records on participants.</li>
</ul>
 A background check (including a criminal records check) must be completed satisfactorily before any candidate can be offered a position with the SJSURF. Failure to satisfactorily complete the background check may affect the application status of applicants or the continued employment of current SJSURF employees who apply for the position. PLEASE NOTE:&nbsp;This position is considered a “sensitive” position by SJSURF and CSU policy. Consequently, the successful candidate must undergo and successfully complete the Live Scan (fingerprinting) background check as a condition of their employment. This background check must be completed before the actual start of employment. NOTE: This position description intends to describe the general nature and level of work being performed by people assigned to this job. It is not intended to include all duties and responsibilities. The order in which duties and responsibilities are listed is not significant. BENEFITS The San José State University Research Foundation (SJSURF) provides an excellent benefits package to benefited employees. The comprehensive benefits package includes:
<ol>
<li>Four company health insurance plans to choose from (employee contributions differ according to plan and level of coverage).</li>
<li>Employer-paid dental and vision for both employee and eligible dependents.</li>
<li>Life, AD&amp;D, LTD with supplemental coverage opportunities.</li>
<li>14 paid federal &amp; state holidays.</li>
<li>Retirement Plan: 403 (b) employee contribution plan component and a 403 (b) employer contribution component, which vests immediately.</li>
<li>Vacation-hour accruals and separate sick-hour accumulations.</li>
<li>Employee discounts.</li>
</ol>
Please visit the&nbsp;<a href="https://www.sjsu.edu/researchfoundation/employees/benefits/index.php" target="_blank">Benefits &amp; Compensation page</a>&nbsp;on the SJSU Research Foundation website for more detailed information.
&nbsp;
APPLICATION PROCEDURE To apply for this position, an applicant must submit a formal application for employment. Select "Apply Now" to complete the SJSURF online employment application.
&nbsp;
REASONABLE ACCOMMODATION The SJSURF is committed to providing access, equal opportunity, and reasonable accommodation for individuals with&nbsp;physical or mental disabilities in the employment, recruitment, examination, interviewing, and hiring processes. If you are a job seeker with a physical or mental disability, and you require a reasonable accommodation to search, apply, or interview&nbsp;for a job opening&nbsp;or otherwise need a reasonable accommodation during the application and hiring process,&nbsp;please contact us at&nbsp;<a href="mailto:foundation-jobs@sjsu.edu" target="_blank">foundation-jobs@sjsu.edu</a>. In the email message, please indicate your full name, phone number and the type of assistance required. You must not reveal the underlying medical reason for your needed reasonable accommodation or otherwise disclose confidential medical information.
&nbsp;
ABOUT THE SJSU RESEARCH FOUNDATION SJSURF employment is separate and distinct from San José State University (SJSU) or state of California employment. SJSURF employees are not employees of SJSU or of the state of California. SJSURF is a non-profit auxiliary of SJSU. SJSURF is totally self-supported. The majority of the organization’s funding comes from the federal government, and other public and private entities. With annual revenues totaling over $65 million, programs managed through SJSURF cover a rich diversity of applied research, public services, and educational-related activities. &nbsp; San José State University Research Foundation is an Equal Opportunity Employer and does not discriminate on the basis of race, color, creed, gender, religion, marital status, registered domestic partner status, age, national origin, ancestry, physical or mental disability, medical condition, sex, genetic information, sexual orientation, military and veteran status or any other consideration made unlawful by federal, state, or local laws. It also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics, or is associated with a person who has or is perceived as having any of those characteristics. It is our policy to provide equal employment opportunities to all employees and applicants for employment. All employment practices such as recruitment, selection, promotions, and other terms and conditions of employment are administered in a manner designed to ensure that employees and applicants for employment or services are not subjected to discrimination. We are committed to providing a work environment free from discrimination and harassment, and where employees are treated with respect and dignity. This policy is in accordance with federal, state and local laws and reaffirms the Research Foundation’s continuing commitment to both the spirit and intent of equal employment opportunity laws and policies. If you have any questions or need assistance or an accommodation in completing this application, please contact Research Foundation HR at (408) 924-5582.

3 Administrative Jobs in California