Minimum 5 years of relevant experience, preferably in Managed Care
Proficient in Microsoft Office Suite
Knowledge of CPT, ICD-10, HCPCS, and billing practices
Familiarity with medical policy and benefit reviews
Ability to act independently with sound clinical judgment
Strong communication skills
Responsibilities
Assist with telephone inquiries regarding member appeals
Identify issues and execute corrective actions with assistance
Triage and prioritize cases to meet regulatory turnaround times
Prepare and submit clinical case reviews to the Medical Director for collaboration
Communicate determinations to members and providers per compliance requirements
Review proper procedure and diagnosis codes for appeals
Initiate referrals to Case Management as needed
Meet individual quality and production metrics based on team goals
Benefits
Hybrid virtual work environment with full-time remote options
Opportunity for professional growth within a specialized team
Engagement in meaningful work impacting member care
Supportive team culture focused on quality and performance
Flexible work schedule with occasional office requirements
Full Job Description
Job Description
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 compliance.
Responsibilities
Your Work
In this role, you will:
Assist with telephone inquiries regarding member appeals
Identify issues, and with assistance, execute corrective action
Triage and prioritize cases to meet required regulatory turn-around times
Prepare and submit clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
Communicate determinations to members and providers in compliance with state, federal and accreditation requirements
Ensure proper procedure codes and diagnosis codes are reviewed for submitted procedures/claims appeal
Initiate referrals for members to Case Management as needs are identified
Adherent to individual contribution expectations for quality and production metrics based on team goal improvements, business performance, company initiatives and operational changes.
Qualifications
Your Knowledge and Experience
Associate's in Nursing required
Bachelor of Science in Nursing preferred
Requires a current, active California RN License
Requires at least 5 years of prior relevant experience, with Managed Care experience preferred.
Proficient skills with Microsoft Office Suite
Knowledge of CPT, ICD-10, HCPCS and billing practices
Knowledge of Medical policy and benefit reviews
Demonstrate the ability to act independently using sound clinical judgement
Solid communication skills
You will be required to work 8 hour shifts Monday-Friday excluding company recognized holidays. You may be required to come into the office on certain days to offset holiday coverage based on business needs.
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
About Blue Shield Of California
Blue Shield of California is a not-for-profit health plan provider that has been providing Californians with access to high-quality healthcare for over 80 years. The company offers a range of health insurance products and services to individuals, families, and employers. Blue Shield of California is committed to improving the health and wellbeing of its members and the communities it serves. The company is also committed to sustainability and has implemented a number of initiatives to reduce its environmental impact.
