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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

<h3>Job Description</h3>
-: 
A Great Place to Work
The Pines at Poughkeepsie is a proud affiliate of National Health Care Associates. As a Certified Great Place to Work, we think that you are going to love it here. Your work will be meaningful to you. You will make a genuine difference in the lives of our aging guests and the families that love them. You will enjoy lasting bonds with the families you meet and with the teams you work on. And if you desire, you will experience real career growth where your expertise and dedication is valued and appreciated. We invite you to join our team!
 -:
What You'll Do:
As a Licensed Practical Nurse, you will play a pivotal role in ensuring the well-being and comfort of our residents. You will provide direct nursing care, administer medications, collaborate with healthcare professionals, and oversee the implementation of care plans.
* Fulltime day and evening shifts available.
* Some part-time and per diem also available
* Weekly pay!
* Sign-On Bonus - $5k for FT and $2,500 for PT
Key Responsibilities:
<ul>
<li>Administering medications and treatments as prescribed by healthcare providers</li>
<li>Monitoring and recording patient vital signs and medical information</li>
<li>Collaborating with the interdisciplinary team to develop and implement care plans</li>
<li>Providing wound care and other nursing interventions as needed</li>
<li>Supervising and supporting Certified Nurse Assistants (CNAs) in delivering care</li>
<li>Ensuring compliance with all regulatory standards and protocols</li>
</ul>
If you are a compassionate and skilled healthcare professional looking to make a significant impact on the lives of others in an environment where compassion, care and expertise come together, we invite you to join our team as a Licensed Practical Nurse (LPN)!
 -:
What We Offer
As an affiliate of National Health Care, our Poughkeepsie team enjoys:
<ul>
<li>Competitive compensation and benefits package</li>
<li>Comprehensive training and mentorship</li>
<li>Opportunities for professional growth and development</li>
<li>Supportive and collaborative work environment</li>
<li>The chance to make a meaningful difference in the lives of our residents</li>
</ul>
 Rate of Pay: USD $28.84 - USD $36.14 /Hr. -:
What You'll Bring:
Qualifications of an Licensed Practical Nurse (LPN) include:
<ul>
<li>Valid state license (LPN)</li>
<li>Compassionate and empathetic approach to patient care</li>
<li>Interest in the nursing needs of the aged and the chronically ill with the ability to work with both</li>
<li>Strong clinical skills including the administration of medications</li>
<li>Excellent communication and interpersonal abilities</li>
<li>Ability to work collaboratively in a multidisciplinary team environment</li>
</ul>
 -:
We Hire for Heart!
National Health Care Associates (National) is proud to be a family-run organization since 1984. Like family, each of National’s centers are unique but share common values:&nbsp;Kindness, Service, Compassion and Excellence. &nbsp;Today, our centers include more than 40 premier providers of short-term rehabilitation, skilled nursing, and post-hospital care including several named “Best Of” by US News &amp; World Report.&nbsp; When you join the team at a National center, you join a team that provides life-changing care to thousands of patients, residents, and families in a Great Place to Work Certified environment.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status.

LPN - Licensed Practical Nurse

<h3>Job Description</h3>
Job Description
Licensed Practical Nurse (LPN)
Join Our Senior Living Community as a Licensed Practical Nurse
Are you a compassionate individual eager to enhance the lives of our beloved senior residents? If this resonates with you, we invite you to become a valued member of our supportive team.
Why Choose Us?
Our organization is dedicated to ensuring a fulfilling life for our residents. Our committed staff plays a crucial role in this vision, offering not only care but also heartfelt companionship. Here, you are more than just a nurse; you are a source of comfort and happiness for those who have shaped our world.
What We Provide:
<ul>
<li>Attractive salary package</li>
<li>Comprehensive benefits including medical, dental, vision, a generous Paid Time Off program, holidays, 401k, and more!</li>
<li>Opportunities for career advancement within a growing organization</li>
<li>Company-sponsored training, tuition reimbursement, and various learning opportunities</li>
</ul>
Your Responsibilities:
As a nurse, you will play an essential role in a caring team focused on enhancing the lives of our residents. Your responsibilities will include:
<ul>
<li>Carefully monitoring patients throughout their treatment, creating a comforting environment within our community.</li>
<li>Conducting routine assessments of patients' vital signs with a gentle approach, prioritizing their comfort and health.</li>
<li>Assisting patients in adhering to their medication schedules, building trust and reliability.</li>
<li>Collaborating effectively with RNs and other healthcare professionals to maintain a harmonious and efficient care setting.</li>
<li>Building strong relationships with patients' families, serving as a liaison to ensure open communication and support for our residents.</li>
</ul>
Qualifications:
<ul>
<li>Possession of a valid, unrestricted LPN license in the state.</li>
<li>A nurturing and empathetic disposition.</li>
<li>Excellent interpersonal and communication abilities.</li>
<li>Proficiency in computer skills.</li>
</ul>
How to Apply:
If you are eager to bring warmth and joy to our senior residents, we would love to hear from you! Please submit your resume and complete a brief application by clicking the APPLY NOW button.
Join us in creating a nurturing environment where our seniors flourish, and each day is filled with smiles and meaningful connections. Your caring presence can truly make a difference.
Still Considering?
Working as a nurse in our senior living community offers a unique set of benefits. Here are some reasons why this role in senior living might be particularly appealing:
<ul>
<li>Personal Connections and Meaningful Relationships: Our nurses often develop deep, lasting bonds with residents, fostering a sense of community and family, which creates a more intimate and rewarding work atmosphere.</li>
<li>Holistic and Individualized Care: We emphasize a comprehensive approach to care, addressing the physical, emotional, and social needs of our residents. Our nurses are integral in delivering tailored care plans that meet individual requirements.</li>
<li>Homely Environment: Our communities are designed to feel like home rather than a clinical facility, promoting a comfortable and familiar setting for both residents and staff, which contributes to a positive workplace.</li>
<li>Diverse Responsibilities: Our nurses engage in a wider range of tasks beyond standard medical care, including organizing activities and facilitating social interactions, enriching the nursing role.</li>
<li>Less Hectic Environment: While healthcare in senior living is vital, it typically operates at a more relaxed pace compared to busy hospitals, allowing our nurses to spend quality time with residents and provide thorough care.</li>
<li>Close Collaboration with Families: Our nurses frequently work alongside residents' families, fostering a supportive and cohesive caregiving environment that encourages open communication.</li>
<li>Improved Work-Life Balance: The generally predictable schedules in senior living can lead to a better work-life balance for our nurses, allowing for more stable and manageable hours.</li>
</ul>
About Us:
“Our ultimate goal is to excel in all we do and to provide a fulfilling life for our residents, their families, and our employees.” - CEO
If you seek a company and team that values individuals, your search ends here!
We are a leading provider of assisted living, memory care, and skilled nursing services in the Western United States. Established in 2012, we have consistently expanded by adding new senior living communities each year. As we continue to grow, we are on the lookout for exceptional talent to join us in our mission to create communities where retired adults can enjoy a high-quality life, and their families can feel assured that their loved ones are safe, happy, and engaged.
We look forward to reviewing your application and hope your skills and talents will help us achieve our goal of providing a rewarding experience for the families in our communities.
We are an equal opportunity employer and do not tolerate discrimination or harassment based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
As part of our ongoing commitment to maintaining a safe environment for all employees, residents, families, and visitors, we strongly encourage our staff to receive an FDA-approved COVID-19 vaccination, along with any recommended booster doses. To support this initiative, we periodically organize onsite vaccination clinics at our various locations. However, being fully vaccinated for COVID-19 is not a requirement for employment.

Licensed Practical Nurse (LPN)

<h3>Job Description</h3>
Job DescriptionLicensed Practical Nurse (LPN) Overview:
The Licensed Practical Nurse (LPN) plays a crucial role in delivering compassionate care to elderly residents within a senior living community. Responsibilities include monitoring vital signs, assisting with medication management, and facilitating communication among residents, families, and healthcare professionals. This position focuses on providing personalized, holistic care in a nurturing environment, fostering strong relationships and a supportive community. The role comes with competitive benefits, opportunities for professional growth, and a balanced work-life schedule within a thriving senior care organization.
LPN - Licensed Practical Nurse
Licensed Practical Nurse - LPN - Senior Living Community
Are you a caring individual eager to positively influence the lives of our beloved senior residents? If so, we invite you to join our friendly and supportive team.
 
Why Choose Us?
We are dedicated to enhancing the lives of our residents. Our committed team is central to this mission, offering not just care but genuine companionship. Here, you are more than just a nurse; you are a source of comfort and joy for those who have shaped our world.
 
What We Provide:
<ul>
<li>Competitive salary</li>
<li>Comprehensive benefits including medical, dental, vision, a generous Paid Time Off program, holidays, 401k, and more!</li>
<li>Opportunities for career advancement within a growing organization</li>
<li>Company-sponsored training, tuition reimbursement, and various learning opportunities.</li>
</ul>
 
Your Responsibilities:
As a nurse, you will be an integral part of a compassionate team focused on enhancing the lives of our residents. Your responsibilities will include:
<ul>
<li>Carefully monitoring patients throughout their treatment, creating a comforting atmosphere within our community.</li>
<li>Conducting routine checks of patients' vital signs with a gentle approach, prioritizing their comfort and well-being.</li>
<li>Assisting in ensuring patients follow their medication schedules, building trust and reliability.</li>
<li>Collaborating effectively with RNs and other healthcare team members to maintain a harmonious and efficient care environment.</li>
<li>Building strong relationships with patients' families, serving as a liaison to promote open communication and support for our residents.</li>
</ul>
 
Qualifications:
<ul>
<li>Must possess a valid, unrestricted LPN license in the state.</li>
<li>A compassionate and caring demeanor.</li>
<li>Excellent interpersonal and communication skills.</li>
<li>Proficiency in computer skills.</li>
</ul>
 
How to Apply:
If you are ready to bring warmth and joy to the lives of our senior residents, we would love to hear from you! Please submit your resume and complete a brief application by clicking the APPLY NOW button.
Join us in creating a nurturing environment where our seniors flourish, and each day is filled with smiles and meaningful connections. Your caring touch can truly make a difference.
 
Still Considering?
Working as a nurse in a senior living community offers a unique set of advantages. Here are some compelling reasons why this role can be particularly rewarding:
<ul>
<li>Personal Connections and Meaningful Relationships: Our nurses often develop deep, lasting bonds with residents, fostering a sense of community and family, which creates a more intimate and fulfilling work environment.</li>
<li>Holistic and Individualized Care: We emphasize a holistic approach, addressing the physical, emotional, and social needs of our residents. Our nurses are key in delivering tailored care plans that meet individual requirements.</li>
<li>Homely Environment: Our communities are designed to feel like home rather than a clinical setting, providing a comfortable and familiar atmosphere for both residents and staff, which contributes to a positive workplace.</li>
<li>Diverse Responsibilities: Our nurses engage in a wider range of tasks beyond traditional medical care, including organizing activities and facilitating social interactions, enriching the nursing role.</li>
<li>Less Hectic Pace: While healthcare in senior living is vital, it often operates at a more relaxed pace compared to busy hospitals, allowing nurses to spend quality time with residents and ensure thorough care.</li>
<li>Close Collaboration with Families: Our nurses frequently work alongside residents' families, fostering a supportive caregiving environment that encourages open communication and understanding.</li>
<li>Improved Work-Life Balance: The generally predictable schedules in senior living contribute to a better work-life balance for our nurses, allowing for more stable and manageable hours.</li>
</ul>
 
About Us:
"Our ultimate goal is to excel in all we do and to provide a fulfilling life for our residents, their families, and our employees." - CEO
If you seek a company and team that values people, your search ends here!
We are a leading provider of assisted living, memory care, and skilled nursing services in the Western United States. Established in 2012, we have consistently expanded by adding new senior living communities each year. As we continue to grow, we are eager to find exceptional talent to join us in our mission to create communities where retired adults can enjoy a high-quality life, and their families can feel assured that their loved ones are safe, happy, and engaged.
We look forward to reviewing your application and hope your skills and talents will help us achieve our goal of providing a rewarding experience for families in our communities.
 
We are an equal opportunity employer and do not tolerate discrimination or harassment based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
As part of our ongoing commitment to maintaining a safe environment for all employees, residents, families, and visitors, we strongly encourage our staff to receive an FDA-approved COVID-19 vaccination, along with any recommended booster doses. To support this initiative, we periodically organize onsite vaccination clinics at our various locations. However, being fully vaccinated for COVID-19 is not a condition of employment.
 Keywords:
Licensed Practical Nurse, LPN, senior living nurse, nursing care, vital sign monitoring, medication administration, patient care, assisted living nursing, holistic senior care, healthcare nursing

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