Your Role
The Medicare 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 Medicare 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 the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, 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.
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
- Ensures proper procedure codes and diagnosis codes are reviewed for submitted procedures/claims appeal
- Initiates appropriate referrals for member’s needs to other departments such as Case Management.
At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We’re excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we’re striving to make a positive change across our industry and the communities we live in , Join us!
Your Knowledge and Experience
- Requires a current CA RN License
- Requires at least 5 years of prior experience in nursing, healthcare or other related fields
- Knowledge of Medicare and Medi-Cal and benefit reviews
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Demonstrate the ability to act independently using sound clinical judgement
Pay Range:
The pay range for this role is: $ 85360.00 to $ 128040.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate’s experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.