Appeals and Grievances - RN, Consultant (MediCare)

About the role

The Medicare 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 Medicare Appeals and Grievances RN Lead will report to the Appeals and Grievances Manager.

Responsibilities

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and Med-Cal, including dual-eligibility products.
• Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.
• Prepare and present appeal and grievance cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
• Lead duties for the team including: managing day to day activities of the team, inventory management, spot audits and monthly internal quality review audits, motivating the team to achieve the organizational goals, facilitating clinical rounds and conducting team training as appropriate.
• Stay current and comply with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.

Qualifications

• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• Requires independent motivation, a strong work ethic, and strong computer navigation skills
• Requires familiarity with electronic health record (EHR) systems
• At least 2 years of Supervisory and/or leadership experience preferred
• General knowledge of claims processing logic/rules
• Comprehensive knowledge of Medicare required
• Comprehensive knowledge of health plan operations, regulatory agencies and state/federal regulations related to health care.

Benefits

Hybrid Virtual Work

About Us

Blue Shield of California

Our Values

Equal Employment Opportunity

Note