Appeals and Grievances - RN, Senior- Medicare

Your Role The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievancesthatare theresultof eitherapreservice,post-service or claimdenial. The Medicare Appeals and Grievances RN Senior will report to Utilization Management Nurse Managerfor Medi-Cal and Medicare Appeals and Grievances. In this role,youwill performaccurate and timely clinical review of provider or member appeals, or appeals initiated by someone qualified to speak on behalfofthe member.TheRN performs redetermination appeal reviews for members utilizingCMS 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. #J-18808-Ljbffr Blue Shield