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L.A. Care Health Plan Logo L.A. Care Health Plan · -

Lead Customer Solution Center Appeals and Grievances RN

United States, Los Angeles 102183.00 - 163492.00 USD / Year · Job Posted December 29, 2025
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Job Description

The Lead Customer Solution Center Appeals and Grievances RN is responsible for assisting with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit. This position is responsible for the quality review of complex and/or escalated clinical A&G cases for all line of business (LOB). The Lead will assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service to L.A. Care’s (LAC) membership. This position will ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures along with all relevant regulatory guidelines. Leads and works closely with assigned team daily. This position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and project completion.

Job Responsibility

  • Assist with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit
  • Quality review of complex and/or escalated clinical A&G cases for all line of business (LOB)
  • Assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service
  • Ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures and regulatory guidelines
  • Lead and work closely with assigned team daily
  • Mentor, coach, and may provide feedback to management on performance of staff
  • Review and process complex and/or escalated clinical A&G cases
  • Analyze patient medical records, clinical documentation, and insurance policies to determine medical necessity
  • Prepare and review A&G files for submission to providers and internal departments
  • Work with other departments to ensure all aspects of a case are appropriately managed
  • Conduct targeted and random clinical case audits
  • Work closely with the leadership team to create and/or modify Desk Level Procedures and recommends enhancements to process and procedures
  • Assist the Clinical Supervisors in identifying deviations in performance and process changes
  • Recommend and implement resolutions, new processes, and/or process improvement
  • Provide accurate and timely written statistical reports
  • Identify and analyze trends in appeals and grievances to find the root cause of denials
  • Check, verify and ensure that all clinical A&G cases are processed accurately and within established timelines
  • Maintain documentation of all communications in the A&G system
  • Lead the work of assigned staff
  • regularly assign and check the work of others, providing guidance, training, and feedback on performance
  • Act as a back-up to the Supervisor in leading meetings and handling escalations as required

Requirements

  • Associate's Degree in Nursing for Registered Nurses
  • At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting
  • At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
  • At least 1 year of leading a process, program, or staff experience
  • Extensive knowledge of healthcare regulations and managed care guidelines
  • Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity
  • Ability to communication, conflict resolution, and motivational skills
  • Ability to work independently and closely with a team in a collaborative and interactive environment
  • Ability to adjust to changing circumstances within the team
  • Good verbal and written communication skills
  • Licensed Registered Nurse (RN) - Active, current and unrestricted California License and/or Physician Assistant (PA) - California License Required

Nice to have

  • Bachelor's Degree in Nursing for Registered Nurses
  • Clinical acute experience
  • Strong project management skills with the ability to manage multiple training initiatives simultaneously

What we offer

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
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