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

Blue Shield of CA; Long Beach (CA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of California's Medi-Cal Member Appeals and Grievances team reviews member appeals and grievances from preservice to claim denial. The RN Senior will perform timely clinical reviews using Milliman Care Guidelines and NCCN/ACOG standards, ensuring medical necessity, coding accuracy and policy compliance.

This hybrid role requires California RN licensure, a nursing degree (BSN preferred), 5+ years in nursing or healthcare, and independent clinical judgement.

Qualifications

• 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.

Responsibilities

• Perform accurate and timely clinical review of member-initiated appeals.
• Review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance.
• Provide clinical oversight of Medi-Cal grievances.
• Collaborate with Medical Directors and coordinators to identify PQI, QOS and QOC cases to address member needs within 30 days or 72 hours if expedited.

Skills

Clinical judgement

Medi-Cal knowledge

Billing codes

Independent worker

Education

Associate's degree in nursing

Bachelor of Science in Nursing

Job description

Blue Shield of California's Medi-Cal Member Appeals and Grievances team reviews member appeals and grievances from preservice to claim denial. The RN Senior will perform timely clinical reviews using Milliman Care Guidelines and NCCN/ACOG standards, ensuring medical necessity, coding accuracy and policy compliance.

This hybrid role requires California RN licensure, a nursing degree (BSN preferred), 5+ years in nursing or healthcare, and independent clinical judgement.