Registered Nurse
1 month ago
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 reviews of Member-initiated appeals. The RNs perform first-level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, 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) Esses to ensure member's clinical needs are addressed appropriately within days or hours if the request is deemed expedited.
Required Skills (top non-negotiables):
. Knowledge of Medi-Cal benefits and reviews
. Requires years of health insurance or related experience
. Demonstrate the ability to act independently using sound clinical judgement
Preferred Skills (nice to have)
. Works well in a fast paced team environment
. Excellent communication skills
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