Appeals & Grievances Nurse

Western Health Advantage•Sacramento, CA

6d•$95,000 - $115,000•Hybrid

About The Position

Western Health Advantage (WHA) is seeking an experienced Appeals & Grievances Nurse (RN) to join our Utilization Management team. This role is ideal for a registered nurse with managed care experience who is passionate about ensuring members receive timely, clinically sound, and compliant reviews of appeals and grievances. Reporting to the Utilization Operations Director, you will collaborate with Medical Directors, Clinical Pharmacists, Appeals & Grievances staff, and contracted provider groups to evaluate complex cases, ensure regulatory compliance, and support exceptional member outcomes.

Requirements

Bachelor's degree in Nursing (BSN).
Active and unrestricted California Registered Nurse (RN) license.
3 years’ experience in utilization/case management, discharge planning and/or appeals & grievances in a managed care environment, with increased responsibilities.
Strong clinical assessment, critical thinking, and analytical skills.
Excellent written and verbal communication skills.
Intermediate Microsoft Office skills, including Excel and Word.
Certification in Utilization Management (CPHM, CMCN, or equivalent), Quality Management, or Certified Case Manager (CCM).
Knowledge of California Department of Managed Health Care (DMHC) regulations.
Familiarity with CMS Medicare regulations.
Experience supporting NCQA accreditation activities.
Experience preparing regulatory responses, audits, or quality improvement initiatives.

Responsibilities

Review medical necessity appeals and grievances requiring clinical evaluation.
Research, analyze, and prepare complex appeal cases involving new technology, experimental treatments, transplants, and other specialized services.
Determine clinical urgency and provide guidance to the Appeals & Grievances team.
Prepare clinical summaries and recommendations for Medical Director review and Appeal Review Meetings.
Draft clinical resolution letters for upheld medical necessity determinations.
Partner with contracted Medical Groups, hospitals, and providers to coordinate member care and facilitate smooth transitions across the continuum of care.
Collaborate with internal departments including Quality Management, Care Management, Member Services, Sales, Marketing, and Wellness on clinical initiatives and special projects.
Assist with referrals to Case Management, Disease Management, and Behavioral Health services.
Provide care coordination and support for members receiving transgender surgery services.
Maintain and update utilization management reference materials, including prior authorization and DME benefit resources.
Support regulatory readiness by participating in DMHC, CMS, and NCQA audits, accreditation activities, RFP responses, and Independent Medical Review submissions.
Participate in conference calls with regulatory agencies and provide clinical expertise on appeals and grievance cases.
Promote compliance with regulatory requirements while ensuring timely, accurate, and member-focused case resolutions.