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

Blue Shield of CA; Oakland (CA); Híbrido; USD 110.000 - 140.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Hybrid work model

Descripción de la vacante

The Blue Shield of CA Medi-Cal Member Appeals and Grievances RN Senior role focuses on timely clinical review of member appeals across pre-service, post-service, and claim denial scenarios. The RN will perform first-level reviews, ensuring medical necessity and policy alignment, while coordinating with Medical Directors on PQI/QOS/QOC cases.

Hybrid virtual work allows remote duties with occasional in-office needs; candidates should have CA RN licensure and at least five years in healthcare,

Formación

• Active, unrestricted CA RN license required.
• Associate's degree in nursing required; BSN preferred.
• Minimum 5 years in nursing or healthcare settings.
• Knowledge of Medi-Cal and benefit reviews.
• Familiarity with CPT, ICD-10, HCPCS and billing practices.
• Ability to work independently with sound clinical judgement.

Responsabilidades

• Clinically review member appeals and grievances for benefits/medical necessity.
• Perform first level appeal reviews using Milliman Care Guidelines and NCCN/ACOG.
• Review Medicare inpatient and outpatient appeals for accuracy and policy compliance.
• Provide clinical oversight of Medi-Cal grievances with the Medical Directors.
• Identify PQI/QOS/QOC cases to address members' clinical needs within 30 days or 72 hours for expedite.

Conocimientos

Clinical judgement

Independent decision-making

Healthcare experience

Educación

Associate's degree in nursing

Bachelor of Science in Nursing (BSN) preferred

Descripción del empleo

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.