Appeals and Grievances - RN, Senior- Medicare

Your Role

The Medicare 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 Senior will report to Utilization Management Nurse Manager for Medi-Cal and Medicare Appeals and Grievances. In this role, you will perform accurate and timely clinical review of provider or member appeals, or appeals initiated by someone qualified to speak on behalf of the member. The RN performs redetermination appeal reviews for members utilizing CMS and/or DHCS approved guidelines, BSC plan policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare, Medi-Cal, including dual-eligibility products; therefore, the Medicare Appeals RN has understanding and knowledge of the Medicare Provider Manual, National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, DHCS Medi-Cal Guidelines, Milliman Care Guidelines (MCG), BSC Pharmacy Policies, BSC Formularies and nationally recognized sources such as NCCN and ACOG. The successful RN candidate will review both medical (Medicare Part B/C) and pharmacy (Medicare Part D) appeals for Medicare/DSNP benefits, medical necessity, coding accuracy and medical policy compliance, as well as grievances for clinical issues.

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.

Your Knowledge and Experience

• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current CA RN License
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields
• Knowledge of Medicare, CMS and health plan benefit reviews
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement
• Knowledge of both medical (Medicare Part B/C) and pharmacy (Medicare Part D) appeals for Medicare/DSNP benefits, medical necessity, coding accuracy and medical policy compliance, as well as grievances for clinical issues strongly preferred

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.