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
Initiate 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

Apply Now

Appeals and Grievances - RN, Senior

Buena Park, CA, 90621