Nurse Supervisor - Grievance & Appeals

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

The Nurse Supervisor - Grievance & Appeals will provide strategic direction and clinical oversight for the review of quality of care grievances, medical claims, and all levels of Medicare Part C and D appeals. Lead and mentor a team of ancillary nurses and medical allies, ensuring consistent, high-quality case review processes. Drive compliance with SCAN's regulatory timeframes through rigorous investigation of care decisions, service management, claims accuracy, and benefits administration. Oversee the auditing, coaching, and performance management of RN reviewers, implementing corrective actions as needed. Continuously evaluate clinical workflows and
escalate identified risks to senior leadership, supporting a culture of accountability, quality improvement, and regulatory excellence.

You Will

• Clinical Oversight Provide clinical expertise and guidance on appeal and grievance cases, ensuring decisions are based on sound clinical judgment and align with medical policies, clinical guidelines, and regulatory requirements.
• Case Review and Decision-Making Conduct or oversee the review of complex appeal and grievance cases, ensuring decisions are clinically appropriate and supported by evidence and policy.
• Training and Development Provide or coordinate training for staff on clinical protocols, regulatory requirements, and internal procedures related to appeals and grievances.
• Quality Assurance Develop, implement, and maintain quality assurance processes to monitor case handling, identify areas for improvement, and ensure compliance with internal standards and external regulations.
• Offshore Resource Management Oversee offshore teams to ensure consistent performance, quality, and adherence to the same standards and expectations as onshore teams.
• Stakeholder Communication Serve as a liaison between the appeals and grievances team and internal departments, senior leadership, external vendors, and regulatory agencies to ensure alignment and transparency.
• Policy Development and Implementation Collaborate with internal stakeholders to develop, update, and implement policies and procedures related to appeals and grievances, ensuring clinical integrity and regulatory compliance.
• Regulatory Compliance Ensure all appeals and grievance activities comply with applicable laws, CMS regulations, and accreditation standards; stay current with changes in the regulatory landscape.
• Team Leadership Supervise and manage a team of nurses and support staff, including offshore resources, to ensure effective and timely case management and resolution of appeals and grievances.
• Data Analysis and Reporting Analyze appeals and grievance data to identify trends, performance gaps, and compliance risks; prepare and present reports to senior leadership and other stakeholders.
• Supervises/Manages Others (i.e. hires, performance reviews, corrective action, etc.)
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN's Vision and Goals.
• Other duties as assigned.

Your Qualifications

• Bachelor's Degree or equivalent experience
• Required Certifications or Licenses: Registered Nurse (RN). RN licensed in the state of CA or willing to seek licensure.
• Health Plan experience required, preferably in Appeals and Grievances, Case Management, or UM.
• Prior supervisory/management experience required.
• Technical expertise - Strong technical skills for functional area
• Problem Solving - Advanced problem solving skills
• Communication - Excellent communication and interpersonal skills. Exceptional oral and written communication skills.
• Team Leadership - Provides leader expertise and sound judgement to drive decisions
• Dynamic Trainer - Creative and proactive in designing diverse learning programs
• Ability to work as part of a team.
• Attentiveness.
• Detail oriented.

What's in it for you?

• Base salary range: $92,400 to $133,671 per year
• Internal title: Nurse Supervisor
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

#LI-MS1

#LI-Hybrid