Appeals and Grievances - RN, Senior

Overview Your Role The 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 Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of member-initiated appeals or appeals initiated on behalf of members from an authorized representative. The RNs perform first level appeal reviews for members utilizing Milliman Care Guidelines, Member Handbook or Evidence of Coverage, Department of Managed Care (DMHC) guidelines, ASAM, WPATH, ABA, CALOCUS, LOCUS and other nationally recognized professional guidelines such as NCCN, NCQA, DOI, and ACOG. The successful RN candidate will review both inpatient and outpatient member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. The leadership model emphasizes developing great leaders at all levels and creating opportunities for personal, professional, and financial growth. We are looking for leaders energized by creative and critical thinking, building and sustaining high-performing teams, achieving results ethically, and fostering continuous learning. Responsibilities Your Work Identify issues, and with assistance, execute corrective action Intake Queue management Prepare and submit clinical case reviews to the Medical Director (MD) for collaboration and medical necessity determination Communicate determinations to the providers in compliance with state, federal and accreditation requirements Work well in a fast-paced, production environment Initiate appropriate referrals for members’ needs to other departments such as Case Management, Utilization Management and Pharmacy Qualifications Your Knowledge and Experience Requires a current CA RN License Requires at least 5 years of prior experience in nursing, healthcare or other related fields with an emphasis on Behavioral Health/Mental Health preferred but not required Bachelor of Science in Nursing or Advanced Degree preferred Knowledge of Commercial, ASO, Medicare Advantage and benefit reviews with emphasis on Behavioral Health/Mental Health appeals review but not required Knowledge of CPT, ICD-10, HCPCS and billing practices Demonstrate the ability to act independently using sound clinical judgement with basic computer skills (Microsoft, shared drives, TEAMS, PDF, etc.) 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. About Us About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. We foster an environment where all employees can thrive and contribute fully to address the needs of the communities we serve. We are committed to maintaining a supportive workplace that upholds our values and goals. Blue Shield is recognized as a Best Company to Work For and as a Top Inspiring Workplace in various rankings. Our Values Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we will do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We foster a workplace environment that balances purposeful in-person collaboration with flexibility. Our model emphasizes intentional in-person interaction, collaboration, connection, creativity and flexibility. For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out-of-state employees, and certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions, we provide reasonable accommodations to support success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements Office environment — roles involve a part to full-time schedule in an office setting, based in physical offices with work from home options. Activity level is sedentary. Equal Employment Opportunity External hires must pass a background check/drug screen. Qualified applicants will be considered in accordance with Federal, State and local laws, including the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration regardless of race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by law. Job Info Job Identification: 20260944 Job Category: Customer Services and Operations Posting Date: 2026-05-21 Job Schedule: Full time Locations: Long Beach, CA; CA; El Dorado Hills, CA; Lodi, CA; Oakland, CA; Rancho Cordova, CA; Redding, CA; San Diego, CA; Woodland Hills, CA Pay Range California: $90,860.00 to $136,290.00 Pay Range Bay Area: $102,424.00 to $153,636.00 Note: Salaries are based on factors including experience, location, and current salaries for similar roles. Role can be filled by a candidate requiring sponsorship: No #J-18808-Ljbffr Blue Shield of California