Appeals and Grievances - RN, Senior (MediCal)

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 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