Grievance & Appeals Nurse Supervisor

Overview

The G&A Nurse Supervisor provides clinical and operational supervision to the Grievance &

Appeals nursing team, including Nurse Specialists, Sr. Nurse Specialists, and State Hearing

Representatives. The Nurse Supervisor maintains an active clinical caseload while overseeing the

daily operations, workload distribution, and performance of the clinical team. The Nurse

Supervisor ensures that casework meets all regulatory and quality standards, including DHCS

guidelines, CMS regulations, NCQA standards, and internal best practices. This position

supports management in driving team performance, upholding productivity and accuracy

standards, and ensuring a cohesive and collaborative team environment. The Nurse Supervisor

exercises advanced clinical judgment to assess, guide, and resolve complex cases and provides

direct support and mentorship to staff. The role represents the department clinically in internal

and external settings, including participation in hearings and key committees, and plays a central

role in the department's clinical oversight and continuous improvement initiatives.

Responsibilities

• Provides clinical and operational supervision to the Grievance and Appeals Nurse

Specialists, Sr. Nurse Specialists, and State Hearing Representatives, including

monitoring workload distribution, performance, and quality of casework.

preparing for hearings, and participating directly in hearings as needed.

and implement clinical process improvements to enhance member experience and

compliance outcomes.

team members, modeling best practices and ensuring adherence to policies and

procedures.

appropriately to internal stakeholders or regulatory bodies.

500 pages per case) to prepare clinical summaries and inform resolution decisions.

clinically appropriate, using member-friendly language.

and clinical review forums.

to their immediate clinical concerns. May refer to Care Coordination for

continued / ongoing case management.

expert (SME) for both internal staff and external partners.

Qualifications

Education and Experience

Bachelor's degree in Healthcare Administration, Business Bachelor's

degree in Nursing, 3-5 years experience to include at least one (1) year

of case management experience and one (1) year in an acute care

setting; or equivalent combination of education and experience. CCM

desired. Knowledge of Partnership Grievance & Appeals processes

desired. General knowledge of managed care with emphasis in UM or

CM preferred.

Special Skills, Licenses and Certifications

Current California Registered Nurse license required. Must be a critical

thinker and organized. Thorough knowledge of utilization and case

management programs and related criteria and protocols. Experience in

managed care business practices and ability to access data information

using computer systems. Ability to work within an interdisciplinary

structure and function independently in a fast-paced environment while

managing multiple priorities and meeting deadlines. Strong

organizational skills required. Effective telephone and computer data

entry skills required.

Performance Based Competencies

Excellent written and verbal communication skills with ability to read

and interpret benefit contract specifications are required. Ability to

apply clinical judgment to complex medical situations and make quick

decisions in a fast-paced environment. Works well under pressure and

maintains professional composure when interacting with all

stakeholders, including members. Works independently, prioritizes

case deliverables, remains customer-focused and stays current on

changes in the healthcare system that may trigger member

dissatisfaction. Can work in a team environment.

Work Environment And Physical Demands

Daily use of telephone and computer for most of the day. Standard

cubicle workstation or telecommute eligible. When required, ability to

move, carry or lift objects weighing up to 25 lbs.

HIRING RANGE :

$136,296.78 - $177,185.82

All HealthPlan employees are expected to :

updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and

the requirements and conditions listed in this job description are representative only and not

exhaustive or definitive of the tasks that an employee may be required to perform. The employer

reserves the right to revise this job description at any time and to require employees to perform

other tasks as circumstances or conditions of its business, competitive considerations, or work

environment change.