Appeals and Grievances RN Senior

Job Summary

The Medi-Cal Appeals and Grievances RN Senior is responsible for conducting clinical reviews of member appeals and grievances related to preservice, post-service, or claim denials. The role involves ensuring accurate and timely reviews of member-initiated appeals, utilizing established guidelines and nationally recognized sources.

Key Responsibilities

• Perform first-level appeal reviews for members using National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care Guidelines, and sources such as NCCN and ACOG.
• Review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
• Provide clinical oversight of all Medi-Cal grievances.
• Collaborate with medical directors and coordinators to identify Potential Quality Issues (PQI), Quality of Service (QOS) cases, and Quality of Care (QOC) cases.
• Ensure members' clinical needs are addressed within 30 days or 72 hours for expedited requests.

Qualifications

• Knowledge of Medi-Cal benefits and review processes.
• Minimum of 2 years of experience in health insurance or a related field.
• Ability to work effectively in a fast-paced team environment.
• Excellent communication skills.
• Demonstrated ability to act independently using sound clinical judgment.

Skills

• Strong analytical and problem-solving skills.
• Ability to manage multiple tasks and prioritize effectively.
• Proficient in using clinical guidelines and resources for decision-making.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one’s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one’s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.

#LI-JH2