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

Blue Shield of CA; Lodi (CA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Blue Shield of California seeks an RN Senior for the Medi-Cal Member Appeals and Grievances team to conduct clinical reviews of member appeals arising from preservice, post-service, or claim denials. The role reports to the Appeals and Grievances Manager and emphasizes timely, evidence-based decision making.

The position requires an active CA RN license, a nursing degree, and at least five years of relevant experience, with knowledge of Medi-Cal, CPT, ICD-10, and billing practices.

Qualifications

• 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 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.

Responsibilities

• Clinically review member appeals and grievances for preservice, post-service or claim denial.
• Perform first level appeal reviews for members using established guidelines.
• Review inpatient and outpatient Medicare member appeals for benefits and medical necessity.
• Ensure coding accuracy and medical policy compliance.
• Provide clinical oversight of Medi-Cal grievances with Medical Directors and coordinators.
• Identify PQI, QOS, and QOC cases to address members' clinical needs within 30 days (72 hours for expedited requests).

Skills

Clinical judgement

Communication

Independent work

Education

Associate's degree in nursing

BSN preferred

Tools

CPT/ ICD-10 knowledge

Billing practices

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.

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.