Senior RN, Medical Appeals & Grievances (Hybrid)

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

Benefits offered by this job

Hybrid work model

Job summary

The Blue Shield of CA Medi-Cal Member Appeals and Grievances RN Senior role focuses on timely clinical review of member appeals across pre-service, post-service, and claim denial scenarios. The RN will perform first-level reviews, ensuring medical necessity and policy alignment, while coordinating with Medical Directors on PQI/QOS/QOC cases.

Hybrid virtual work allows remote duties with occasional in-office needs; candidates should have CA RN licensure and at least five years in healthcare,

Qualifications

• Active, unrestricted CA RN license required.
• Associate's degree in nursing required; BSN preferred.
• Minimum 5 years in nursing or healthcare settings.
• Knowledge of Medi-Cal and benefit reviews.
• Familiarity with CPT, ICD-10, HCPCS and billing practices.
• Ability to work independently with sound clinical judgement.

Responsibilities

• Clinically review member appeals and grievances for benefits/medical necessity.
• Perform first level appeal reviews using Milliman Care Guidelines and NCCN/ACOG.
• Review Medicare inpatient and outpatient appeals for accuracy and policy compliance.
• Provide clinical oversight of Medi-Cal grievances with the Medical Directors.
• Identify PQI/QOS/QOC cases to address members' clinical needs within 30 days or 72 hours for expedite.

Skills

Clinical judgement

Independent decision-making

Healthcare experience

Education

Associate's degree in nursing

Bachelor of Science in Nursing (BSN) preferred

Job description

The Blue Shield of CA Medi-Cal Member Appeals and Grievances RN Senior role focuses on timely clinical review of member appeals across pre-service, post-service, and claim denial scenarios. The RN will perform first-level reviews, ensuring medical necessity and policy alignment, while coordinating with Medical Directors on PQI/QOS/QOC cases.

Hybrid virtual work allows remote duties with occasional in-office needs; candidates should have CA RN licensure and at least five years in healthcare,