Appeals and Grievances - RN, Senior- Medicare

Job Title

Medicare Appeals And Grievances Rn Senior

Job Description

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

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.

Responsibilities

Your Work

In this role, you will:

• Assist review of clinical documentation with case prep regarding member appeals
• Manage caseload that adheres to regulatory compliance requirements
• Process clinical oversight review of grievances for dual-eligible members
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
• Communicate determinations to the providers and/or members in compliance with state, federal and accreditation requirements
• Ensure proper procedure codes, diagnosis codes, drug names and dosages are reviewed for submitted procedures/service claims/pharmacy appeal
• Initiates appropriate referrals for members' needs to other departments such as Case Management.
• Work collaboratively with business partners, including vendors, to ensure compliance and performance expectations are met

Qualifications

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.

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 genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to 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 believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around 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 employees in certain member-facing roles should work with their manager to determine in-office time based on business need.

• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their 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 involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Job Info

• Job Identification 20260777
• Job Category Customer Services and Operations
• Posting Date 04/29/2026, 05:57 PM
• Job Schedule Full time
• Locations US-CA-Long Beach-Kilroy Airport
• Pay Range for California $90860.00 to $136290.00
• Pay Range for Bay Area $102424.00 to $153636.00
• Note Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
• Role can be filled by a candidate requiring sponsorship No