Senior RN, Medi-Cal Appeals & Grievances (Hybrid)

Blue Shield of CA; Lodi (CA); Hybrid; USD 90.000 - 130.000; Vollzeit

Zusammenfassung

Blue Shield of California seeks an RN Senior for the Medi-Cal Member Appeals and Grievances team to conduct clinical reviews of member appeals arising from preservice, post-service, or claim denials. The role reports to the Appeals and Grievances Manager and emphasizes timely, evidence-based decision making.

The position requires an active CA RN license, a nursing degree, and at least five years of relevant experience, with knowledge of Medi-Cal, CPT, ICD-10, and billing practices.

Qualifikationen

• 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 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.

Aufgaben

• Clinically review member appeals and grievances for preservice, post-service or claim denial.
• Perform first level appeal reviews for members using established guidelines.
• Review inpatient and outpatient Medicare member appeals for benefits and medical necessity.
• Ensure coding accuracy and medical policy compliance.
• Provide clinical oversight of Medi-Cal grievances with Medical Directors and coordinators.
• Identify PQI, QOS, and QOC cases to address members' clinical needs within 30 days (72 hours for expedited requests).

Kenntnisse

Clinical judgement

Communication

Independent work

Ausbildung

Associate's degree in nursing

BSN preferred

Tools

CPT/ ICD-10 knowledge

Billing practices

Jobbeschreibung

Blue Shield of California seeks an RN Senior for the Medi-Cal Member Appeals and Grievances team to conduct clinical reviews of member appeals arising from preservice, post-service, or claim denials. The role reports to the Appeals and Grievances Manager and emphasizes timely, evidence-based decision making.

The position requires an active CA RN license, a nursing degree, and at least five years of relevant experience, with knowledge of Medi-Cal, CPT, ICD-10, and billing practices.