California Licensed Grievance Nurse

To facilitate medical necessity grievances and appeals, the full-time California Licensed Grievance Nurse will review clinical data, manage denial notifications, and prepare case reviews for the Medical Director while working remotely on PST hours. Key responsibilities Review clinical data to determine claim payment based on company policies and NCQA guidelines Prepare case reviews for the Medical Director when criteria are not met and identify quality care concerns Generate appeal resolution communications to members and providers in accordance with company policies Required qualifications Current California RN, LPN, or LVN license RN with 2+ years or LPN/LVN with 3+ years of clinical nursing experience Experience with utilization or appeals review preferred Knowledge of InterQual criteria preferred