Appeals and Grievances - RN, Senior

Your Role The 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 Appeals and Grievances RN Senior will report to the  Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of member-initiated appeals or appeals initiated by someone qualified to speak on behalf of the member.  The RNs perform first and second level appeal reviews for members utilizing Evidence of Coverage, BSC evidenced based guidelines, policies, and nationally recognized clinical criteria. The successful RN candidate will review both medical and pharmacy member appeals for benefits, medical necessity, coding accuracy and medical policy complianceYour WorkIn this role, you will:Assist with telephone inquiries regarding member appeals Identify issues, and with assistance, execute corrective actionTriages and prioritizes cases to meet required regulatory turn-around timesPrepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination Communicates determinations to members and providers in compliance with state, federal and accreditation requirementsEnsures proper procedure codes and diagnosis codes are reviewed for submitted procedures/claims appealInitiate referrals for members to Case Management as needs are identifiedYour Knowledge and ExperienceBachelors of Science in Nursing or advanced degree preferred Requires a current California RN License Requires at least 5 years of prior relevant experienceProficient skills with Microsoft Office SuiteKnowledge of CPT, ICD-10, HCPCS and billing practicesKnowledge of Medical policy and benefit reviewsDemonstrate the ability to act independently using sound clinical judgementSolid communication skills

Created: 2025-03-01