Job DescriptionYour 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..
ResponsibilitiesYour 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.
QualificationsYour 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 WorkThis 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.
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