Appeals and Grievances - RN, Senior (Medi-Cal)

Blue Shield of California; California; Hybrid; USD 91,000 - 136,000; Full time

Job summary

Blue Shield of California is seeking a Senior RN in Medi-Cal Appeals and Grievances to perform clinical reviews of member appeals and grievances, including pre- and post-service denials, and to ensure medical necessity and policy compliance.

The role reports to the Appeals and Grievances Manager; hybrid virtual work with some in-office needs; requires CA RN license and 5+ years experience; CPT/ICD-10 knowledge and use of Milliman Care Guidelines.

Qualifications

• Active, unrestricted California RN license.
• Associate's degree in nursing required.
• BSN preferred.
• 5+ years nursing or related experience.
• Knowledge of Medi-Cal processes.
• Knowledge of CPT, ICD-10, HCPCS and billing.

Responsibilities

• Identify issues and, with assistance, execute corrective action.
• Intake Queue.
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination.
• Communicates determinations to the providers in compliance with state, federal and accreditation requirements.
• Works well in a fast paced, production environment.
• Initiates appropriate referrals for members’ needs to other departments such as Case Management.

Skills

CA RN license

Associate's degree in nursing

BSN preferred

5+ years healthcare experience

Medi-Cal knowledge

CPT/ICD-10/HCPCS knowledge

Education

Associate's degree in nursing

BSN

Job description

Your Role

The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals. The RNs perform first level appeal reviews for members utilizing Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the Medical Directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member’s clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.

Job Description

Your Role

The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals. The RNs perform first level appeal reviews for members utilizing Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the Medical Directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member’s clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work

In this role, you will:

• Identify issues, and with assistance, execute corrective action
• Intake Queue
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
• Communicates determinations to the providers in compliance with state, federal and accreditation requirements
• Works well in a fast paced, production environment
• Initiates appropriate referrals for members’ needs to other departments such as Case Management.

Qualifications

Your Knowledge and Experience

• Must maintain an active, unrestricted CA RN license
• Associate’s degree in nursing is required
• Bachelor of Science in Nursing is preferred
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields
• Requires knowledge of Medi-Cal and benefit reviews
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

JOB INFO

Job Identification : 20261885 Job Category : Customer Services and Operations Posting Date : 2026-10-07T18:08:35+00:00 Job Schedule : Full time Locations : Rancho Cordova, CA, United States CA, United States Long Beach, CA, United States El Dorado Hills, CA, United States Lodi, CA, United States Oakland, CA, United States Redding, CA, United States San Diego, CA, United States Woodland Hills, CA, United States Pay Range for California : $90860.00 to $136290.00 Pay Range for Bay Area : $102424.00 to $153636.00 Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles. Role can be filled by a candidate requiring sponsorship : No