Description As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You will: + Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with clinical and administrative teams. + Assessing cases to determine the appropriateness of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies. + Identifying and investigating Potential Quality Issues (PQIs) to ensure continuous improvement in care delivery. + Complete other duties as assigned. Salary Range: $61.79-$79.91/hourlyQualifications We're seeking a highly qualified candidate with: * A BSN or MSN degree, required * Current valid California RN license, required * Minimum of 2 years' experience in a managed care or Medicare Advantage setting is highly desired * Experience in handling appeals, grievances, utilization management, or potential quality issues * Knowledge of Medicare Advantage plan operations and CMS regulations, highly desired * Strong clinical assessment and decision-making skills, particularly in evaluating medical necessity * Thorough understanding of Medicare Advantage regulations, especially related to appeals, grievances, and PQIs, highly desired * Excellent written and verbal communication skills to communicate complex medical information to members and providers effectively * Proficiency in Microsoft Office Suite and case management software UCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person’s unique achievements and experiences to further set us apart.