Senior RN, Appeals & Grievances - Hybrid/Remote

Blue Shield of CA; Rancho Cordova (CA); Hybrid; USD 110,000 - 140,000; Full time

Job summary

Blue Shield of Californias Medi-Cal Member Appeals and Grievances team reviews member appeals and grievances arising from preservice, post-service, or claim denials. The RN Senior will conduct first-level reviews using established guidelines and trusted medical sources.

This hybrid role emphasizes leadership, collaboration with Medical Directors, and ensuring timely resolution of cases within 30 days or 72 hours if expedited, while supporting professional growth.

Qualifications

• Active, unrestricted CA RN license.
• Associate's degree in nursing required.
• Bachelor of Science in Nursing is preferred.
• At least 5 years of prior experience in nursing, healthcare or related fields.
• Knowledge of Medi-Cal and benefit reviews.
• Knowledge of CPT, ICD-10, HCPCS and billing practices.
• Ability to act independently using sound clinical judgement.

Responsibilities

• Perform accurate and timely clinical review of member appeals.
• Review inpatient and outpatient Medicare member appeals for benefits and medical necessity.
• Provide clinical oversight of Medi-Cal grievances and coordinate with Medical Directors.
• Ensure PQI, QOS and QOC cases are addressed within 30 days or 72 hours for expedited requests.

Skills

Active CA RN license

Clinical judgement

Independent worker

Healthcare knowledge

Education

Associate's degree in nursing

Bachelor of Science in Nursing (BSN) preferred

Tools

CPT coding

ICD-10 coding

Billing practices

Job description

Blue Shield of Californias Medi-Cal Member Appeals and Grievances team reviews member appeals and grievances arising from preservice, post-service, or claim denials. The RN Senior will conduct first-level reviews using established guidelines and trusted medical sources.

This hybrid role emphasizes leadership, collaboration with Medical Directors, and ensuring timely resolution of cases within 30 days or 72 hours if expedited, while supporting professional growth.