Job Description

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.

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 Work

In this role, you will:

• Identify issues, and with assistance, execute corrective action
• Intake Queue
• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
• Communicates determinations to the providers in compliance with state, federal and accreditation requirements
• Works well in a fast paced, production environment
• Initiates appropriate referrals for members’ needs to other departments such as Case Management, Utilization Management and Pharmacy.

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 acquired basic computer skillset utilizing programs such as 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.