Your Role
The Medi-Cal 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 Medi-Cal 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. The RNs perform first level appeal reviews for membersutilizingMilliman Care Guidelines, Member Handbook or Evidence of Coverage, Medi-Cal (DHCS) guidelines and other nationally recognized professional guidelines such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medi-Cal member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member’s clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.
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 member’s needs to other departments such as Case Management.
Your Knowledge and Experience
- Requires a current CA RN License
- Bachelor of Science in Nursing or Advanced Degree preferred
- Requires at least 5 years of prior experience in nursing, healthcare or other related fields
- Knowledge of Medicare and Medi-Cal and benefit reviews
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Demonstrate the ability to act independently using sound clinical judgement