Senior RN: Appeals & Grievances (Hybrid)

Blue Shield of CA; San Diego (CA); Ibrido; USD 110.000 - 140.000; Tempo pieno

Descrizione del lavoro

Blue Shield of California is seeking an experienced RN for the Medi-Cal Member Appeals and Grievances team. The RN Senior will conduct clinical reviews of member appeals, using established guidelines and reputable sources, and will collaborate with Medical Directors to address PQI/QOS/QOC cases.

You will work in a hybrid virtual capacity, providing leadership and timely decisions to ensure members receive appropriate benefits and care.

Competenze

• Active, unrestricted CA RN license is required.
• Associate degree in nursing required; Bachelor's is preferred.
• At least 5 years of experience in nursing, healthcare or related field.
• Knowledge of Medi-Cal and benefit reviews.
• Knowledge of CPT, ICD-10, HCPCS and billing practices.

Mansioni

• Clinically review member appeals and grievances (preservice, post-service or claim denial).
• Perform first-level appeal reviews using Milliman Care Guidelines and NCCN/ACOG references.
• Coordinate with Medical Directors and coordinators to identify PQI/QOS/QOC cases.
• Ensure timely resolution within 30 days (or 72 hours if expedited).

Conoscenze

Active CA RN license

Clinical judgement

Medi-Cal knowledge

CPT/ICD-10 coding

Billing practices

Formazione

Associate's degree in nursing

Bachelor of Science in Nursing (preferred)

Descrizione del lavoro

Blue Shield of California is seeking an experienced RN for the Medi-Cal Member Appeals and Grievances team. The RN Senior will conduct clinical reviews of member appeals, using established guidelines and reputable sources, and will collaborate with Medical Directors to address PQI/QOS/QOC cases.

You will work in a hybrid virtual capacity, providing leadership and timely decisions to ensure members receive appropriate benefits and care.