Note: The job is a remote job and is open to candidates in USA. Blue Shield of California is a nonprofit health plan focused on creating an affordable, high-quality healthcare system. The Senior Medi-Cal Appeals and Grievances RN performs timely clinical reviews of member appeals and provides clinical oversight of grievances, collaborating with Medical Directors and coordinators to address medical necessity, benefits, coding, and quality-of-care issues.

Responsibilities

• Identify issues, and with assistance, execute corrective action
• Intake Queue
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
• Communicates determinations to the providers in compliance with state, federal and accreditation requirements
• Works well in a fast paced, production environment
• Initiates appropriate referrals for members’ needs to other departments such as Case Management

Skills

• Must maintain an active, unrestricted CA RN license
• Associate's degree in nursing is required
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields
• Requires knowledge of Medi-Cal and benefit reviews
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement
• Bachelor of Science in Nursing is preferred

Benefits

• For most teams, this means coming into the office two days per week.
• This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

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