Senior RN, Medi-Cal Appeals & Grievances - Hybrid

Blue Shield of California; Rancho Cordova (CA); Híbrido; USD 95.000 - 135.000; Jornada completa

Descripción de la vacante

Blue Shield of California seeks an RN Senior to clinically review Medi-Cal member appeals and grievances. You will perform first level reviews using established guidelines and document medical necessity and coding accuracy.

You will coordinate with Medical Directors and staff to address PQI/QOS/QOC cases within the required timeframes. Hybrid virtual work enables some remote days, with in-office visits as needed for business requirements.

Formación

• Must hold an active, unrestricted CA RN license.
• 5+ years nursing/healthcare experience.
• Knowledge of Medi-Cal and benefit reviews.
• Familiarity with CPT, ICD-10, HCPCS and billing practices.

Responsabilidades

• Clinically review member appeals and grievances (preservice, post-service, or denials).
• Perform first level appeal reviews using guidelines and evidence-based sources.
• Provide clinical oversight of Medi-Cal grievances with timelines (30 days or expedited 72 hours).
• Collaborate with Medical Directors and coordinators to ensure member needs are addressed.

Conocimientos

Clinical judgement

Independent decision making

Communication

Educación

Associate’s degree in nursing

Bachelor of Science in Nursing preferred

Descripción del empleo

Blue Shield of California seeks an RN Senior to clinically review Medi-Cal member appeals and grievances. You will perform first level reviews using established guidelines and document medical necessity and coding accuracy.

You will coordinate with Medical Directors and staff to address PQI/QOS/QOC cases within the required timeframes. Hybrid virtual work enables some remote days, with in-office visits as needed for business requirements.