Appeals and Grievances RN

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 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.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work 

In this role, you will: 

• 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.

Qualifications

Your Knowledge and Experience 

• Must maintain an active, unrestricted CA RN license

• Associate’s degree in nursing is required

• Bachelor of Science in Nursing is preferred

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

• Requires knowledge of Medi-Cal and benefit reviews