Senior RN, Medical Appeals & Grievances - Hybrid

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

Job summary

Blue Shield of California's Medi-Cal Member Appeals and Grievances team seeks an RN Senior to conduct clinical reviews of member appeals arising from preservice, post-service, or claim denial. The role reports to the Appeals and Grievances Manager and focuses on timely, evidence-based decisions.

You will work with Medical Directors and coordinators to identify PQI, QOS, and QOC cases, ensuring members' clinical needs are met within 30 days or within 72 hours for expedited requests, while

Qualifications

• Active, unrestricted CA RN license.
• Associate's degree in nursing required.
• BSN 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 coding and billing practices.
• Demonstrate the ability to act independently using sound clinical judgement.

Responsibilities

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

Skills

Clinical review

Independent judgement

Healthcare knowledge

Medi-Cal knowledge

Education

Associate's degree in nursing

Bachelor of Science in Nursing

Tools

CPT coding

ICD-10 coding

Billing practices

Job description

Blue Shield of California's Medi-Cal Member Appeals and Grievances team seeks an RN Senior to conduct clinical reviews of member appeals arising from preservice, post-service, or claim denial. The role reports to the Appeals and Grievances Manager and focuses on timely, evidence-based decisions.

You will work with Medical Directors and coordinators to identify PQI, QOS, and QOC cases, ensuring members' clinical needs are met within 30 days or within 72 hours for expedited requests, while