Appeals and Grievances - RN, Senior

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 Milliman Care Guidelines, Member Handbook or Evidence of Coverage, Medi-Cal (DHCS) guidelines and other nationally recognized professional guidelines such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medi-Cal 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 Knowledge and Experience

• Requires a current CA RN License
• Bachelor of Science in Nursing or Advanced Degree preferred
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields
• Knowledge of Medicare and Medi-Cal and benefit reviews
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement