Senior Appeals & Grievances RN — Hybrid

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

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.