Appeals and Grievances - RN, Consultant

Your Role

The Medicare and Medi-cal 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 Medicare Appeals and Grievances RN Lead will report to the Appeals and Grievances Manger. In this role you will be leading a team of nurses who will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG.

Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate will have previous leadership experience, hold an active CA license from Board of Registered Nurses and higher-level certifications are highly desirable.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• Requires independent motivation, a strong work ethic, and strong computer navigation skills
• Requires familiarity with electronic health record (EHR) systems
• At least 2 years of Supervisory and/or leadership experience preferred
• General knowledge of claims processing logic/rules
• Comprehensive knowledge of health plan operations, regulatory agencies and state/federal regulations related to health care.