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Blue Shield of California · 20 hours ago

Appeals and Grievances - RN, Senior

El Dorado Hills, CA, United States

Full-time

Onsite

Mid, Senior Level

$102K/yr - $154K/yr

5+ years exp

Blue Shield of California is seeking a Senior RN for their Medicare Appeals and Grievances team. The role involves clinically reviewing member appeals and grievances, ensuring compliance with regulations, and collaborating with various stakeholders to manage appeals effectively.

Financial ServicesHealth InsuranceNon Profit

No H1B

Responsibilities

Assist review of clinical documentation with case prep regarding member appeals

Manage caseload that adheres to regulatory compliance requirements

Process clinical oversight review of grievances for dual-eligible members

Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination

Communicate determinations to the providers and/or members in compliance with state, federal and accreditation requirements

Ensure proper procedure codes, diagnosis codes, drug names and dosages are reviewed for submitted procedures/service claims/pharmacy appeal

Initiates appropriate referrals for members’ needs to other departments such as Case Management

Work collaboratively with business partners, including vendors, to ensure compliance and performance expectations are met

Qualification

CA RN LicenseMedicare knowledgeCPTICD-10HCPCS knowledge5 years nursing experienceClinical judgement

Required

Requires a current CA RN License

Requires at least 5 years of prior experience in nursing, healthcare or other related fields

Knowledge of Medicare, CMS and health plan benefit reviews

Knowledge of CPT, ICD-10, HCPCS and billing practices

Demonstrate the ability to act independently using sound clinical judgement

Preferred

Bachelor of Science in Nursing or advanced degree preferred

Knowledge of both medical (Medicare Part B/C) and pharmacy (Medicare Part D) appeals for Medicare/DSNP benefits, medical necessity, coding accuracy and medical policy compliance, as well as grievances for clinical issues strongly preferred