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.
• Serves as the primary clinical lead for the department, representing G&A in crossfunctional committees, external meetings, and State Hearings as needed.
• Oversees and supports the State Hearing Representatives by reviewing clinical content,
preparing for hearings, and participating directly in hearings as needed.
• Collaborates with management to assess team performance, identify areas for training,
and implement clinical process improvements to enhance member experience and
compliance outcomes.
• Conducts training and provides mentorship to nursing staff and clinical support for other
team members, modeling best practices and ensuring adherence to policies and
procedures.
• Identifies quality of care concerns, potential fraud, waste, and abuse, and escalates
appropriately to internal stakeholders or regulatory bodies.
• Reviews and synthesizes complex medical records and clinical information (typically 30-
500 pages per case) to prepare clinical summaries and inform resolution decisions.
• Partners with G&A Case Analysts to ensure resolution letters are medically accurate and
clinically appropriate, using member-friendly language.
• Ensures team adherence to DHCS, CMS, and NCQA requirements and contributes to the development and maintenance of clinical desktop procedures and audit readiness materials.
• Participates in regular team and cross-departmental meetings, strategic planning sessions,
and clinical review forums.
• In coordination with the G&A Case Analyst, may contact members as it directly relates
to their immediate clinical concerns. May refer to Care Coordination for
continued/ongoing case management.
• Documents all casework activity thoroughly, accurately, timely, and ethically.
• Provides back-up coverage for clinical staff as needed and serves as a subject matter
expert (SME) for both internal staff and external partners.
• Other duties as assigned.
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:
• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be
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.

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Grievance & Appeals Nurse Supervisor

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