Grievance and Appeals Nurse

Akkodis is hiring a Grievance and Appeals Nurse (LVN) to support our client in the healthcare space! Location: Remote (must be located in California) Employment type: 3 Month contract (potential for extension) Pay Rate: $36 per hour Under general supervision, the Grievance and Appeals Nurse (LVN) is responsible for investigating and processing grievances and appeals in alignment with internal policies, regulatory requirements, and organizational objectives. This role requires strong clinical knowledge within the California LVN scope of practice, as well as the ability to manage case reviews, conduct clinical assessments, and collaborate effectively with both internal and external stakeholders. The ideal candidate is detail-oriented, adaptable, and capable of working independently while contributing as a team player in a fast-paced managed care environment.

Conduct investigations and clinical reviews of member grievances and appeals, including prospective, concurrent, and retrospective medical records related to denied services. Prepare and distribute case summaries and recommendations for both internal and external medical reviewers. Review and ensure regulatory compliance of member and practitioner Notice of Action (NOA) letters; escalate issues as needed. Generate timely, accurate written correspondence to members, providers, and regulatory entities. Collaborate with internal departments and external partners to ensure the accuracy and timeliness of appeal-related documentation and reports. Investigate and complete clinical reviews of Independent Medical Reviews (IMR) and State Fair Hearings (SFH); prepare and submit health plan responses and participate in SFH proceedings as required. Enter and manage data within multiple databases and systems. Assist in the continuous improvement of processes related to grievance and appeal handling. Maintain confidentiality and handle sensitive information with discretion.