Job DescriptionYour 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.
ResponsibilitiesYour 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.
QualificationsYour 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
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Demonstrate the ability to act independently using sound clinical judgement
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.
Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
- For most teams, this means coming into the office two days per week.
- Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
- For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
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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