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 compliance.

Your Work

In this role, you will:

• Assist with telephone inquiries regarding member appeals 
• Identify issues, and with assistance, execute corrective action

• Triages and prioritizes cases to meet required regulatory turn-around times

• Prepares 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 requirements

• Ensures proper procedure codes and diagnosis codes are reviewed for submitted procedures/claims appeal

• Initiates referrals for members to Case Management as needs are identified

Your Knowledge and Experience

• Bachelors of Science in Nursing or advanced degree preferred
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience

• 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