Your Role

The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals. The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member's clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.

Your Work

In this role, you will:

• Identify issues, and with assistance, execute corrective action
• Intake Queue
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
• Communicates determinations to the providers in compliance with state, federal and accreditation requirements
• Works well in a fast paced, production environment
• Initiates appropriate referrals for member's needs to other departments such as Case Management.

Your Knowledge and Experience

• Bachelors of Science in Nursing or advanced degree preferred.
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Proficient skills with Microsoft Office Suite
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Knowledge of Medicare and Medi-Cal and benefit reviews preferred
• Demonstrate the ability to act independently using sound clinical judgement
• Requires advanced knowledge of appeals and grievances typically obtained through advanced education combined with experience.
• Solid communication skills

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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