Appeals and Grievances - RN, Senior

California Physicians' Service - Rancho Cordova, CA

Full-time - Mid Level

Rancho Cordova, CA

Insurance Carriers and Related Activities

About the position

The Medi-Cal Appeals and Grievances RN Senior is responsible for clinically reviewing member appeals and grievances related to preservice, post-service, or claim denials. This role involves performing accurate and timely clinical reviews of member-initiated appeals, ensuring compliance with various guidelines and policies, and collaborating with medical directors to address potential quality issues within specified timeframes.

Responsibilities

• Perform accurate and timely clinical review of member-initiated appeals.
• Utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, and Milliman Care Guidelines for appeal reviews.
• Review inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
• Perform clinical oversight of all Medi-Cal grievances.
• Work with medical directors and coordinators to identify Potential Quality Issues (PQI), Quality of Service (QOS) cases, and Quality of Care (QOC) cases.
• Prepare and submit clinical case reviews to the Medical Director for collaboration and medical necessity determination.
• Communicate determinations to providers in compliance with state, federal, and accreditation requirements.
• Initiate appropriate referrals for member needs to other departments such as Case Management.

Requirements

• Bachelor of Science in Nursing or advanced degree preferred.
• Current California RN License required.
• At least 5 years of prior relevant experience required.
• Proficient skills with Microsoft Office Suite.
• Knowledge of CPT, ICD-10, HCPCS, and billing practices required.
• Knowledge of Medicare and Medi-Cal and benefit reviews preferred.
• Ability to act independently using sound clinical judgment required.
• Advanced knowledge of appeals and grievances typically obtained through advanced education combined with experience required.
• Solid communication skills.

Benefits

• Competitive salary range of $87,230.00 to $130,900.00 based on experience and location.