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

Blue Shield of CA; Los Angeles (CA); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Blue Shield of CA is seeking an RN Senior to lead the Medi-Cal Member Appeals and Grievances team, performing clinical reviews of member appeals and ensuring medical necessity and policy compliance. You will work with Medical Directors and coordinators to address PQI/QOS/QOC cases within required timeframes.

The role supports a hybrid work arrangement with office visits as needed, and requires an active CA RN license, nursing experience, and Medi-Cal expertise.

Qualifications

• Active, unrestricted California RN license.
• Associate degree in nursing required.
• BSN preferred.
• Minimum 5 years of nursing or healthcare experience.
• Knowledge of Medi-Cal and benefit reviews.
• Familiarity with CPT, ICD-10, HCPCS and billing practices.

Responsibilities

• Perform accurate and timely clinical review of member appeals.
• Review inpatient and outpatient Medicare member appeals for medical necessity and policy compliance.
• Collaborate with Medical Directors and coordinators to identify PQI, QOS, and QOC cases.

Skills

Active CA RN license

5+ years nursing experience

Medi-Cal knowledge

Billing/CPT/ICD-10 knowledge

Independent clinical judgement

Education

Associate's degree in nursing

BSN preferred

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.