We have other current jobs related to this field that you can find below
-
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
Appeals and Grievances
3 months ago
El Dorado Hills, United States Blue Shield of California Full timeYour Role The 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 Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of...
-
Appeals and Grievances
3 months ago
El Dorado Hills, United States Blue Shield of California Full timeYour Role The 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 Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of...
-
Appeals and Grievances
1 month ago
El Dorado Hills, United States Blue Shield of California Full timeYour Role The 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 Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of...
-
El Dorado Hills, United States Blue Shield of California Full timeYour RoleThe Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
El Dorado Hills, CA, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
United States, CA, El Dorado Hills Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
El Dorado Hills, CA, United States Blue Shield of California Full timeYour Role The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to...
-
Woodland Hills, United States Blue Shield of California Full timeYour Role The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to...
-
Woodland Hills, United States Blue Shield of California Full timeYour Role The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to...
-
Woodland Hills, United States Blue Shield of California Full timeYour Role The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to...
-
Woodland Hills, United States Blue Shield of California Full timeYour Role The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to...
-
United States, CA, Woodland Hills Blue Shield of California Full timeYour Role The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to...
-
Operations Specialist, Experienced
2 weeks ago
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Commercial Appeals and Grievances team performs comprehensive research related to the facts and circumstances of member complaints, appeals and grievances. The Commercial Appeals and Grievances Operations Specialist - Experienced will report to a Commercial Appeals and Grievances Supervisor. In this role you will partner with the Commercial...
-
Supervisor, Operations
2 weeks ago
El Dorado Hills, United States Blue Shield of California Full timeYour Role The Commercial Appeals & Grievances department performs comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. The Commercial Appeals & Grievances Supervisor will report to the Commercial Appeals & Grievances Senior Manager. In this role, you will be accountable for hiring, promoting,...
-
Operations Specialist, Experienced
3 weeks ago
El Dorado Hills, United States Blue Shield Of California Full timeYour Role The Commercial Appeals and Grievances team performs comprehensive research related to the facts and circumstances of member complaints, appeals and grievances. The Commercial Appeals and Grievances Operations Specialist - Experienced will report to a Commercial Appeals and Grievances Supervisor. In this role you will partner with the Commercial...
-
Operations Specialist, Experienced
1 week ago
El Dorado Hills, United States Blue Shield Of California Full timeYour Role The Commercial Appeals and Grievances team performs comprehensive research related to the facts and circumstances of member complaints, appeals and grievances. The Commercial Appeals and Grievances Operations Specialist - Experienced will report to a Commercial Appeals and Grievances Supervisor. In this role you will partner with the Commercial...
Appeals and Grievances
1 month ago
Your Role
The 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 Manager of the Appeals and Grievances team. In this role you will perform accurate and timely clinical review of member-initiated appeals or appeals initiated by someone qualified to speak on behalf of the member. The RNs perform first and second level appeal reviews for members utilizing Evidence of Coverage, BSC evidenced based guidelines, policies, and nationally recognized clinical criteria. The successful RN candidate will review both medical and pharmacy member appeals for benefits, medical necessity, coding accuracy and medical policy compliance.
Your Work
In this role, you will:
- Assist with telephone inquiries regarding member appeals
- Identify issues, and with assistance, execute corrective action
- Triages and prioritizes cases to meet required regulatory turn-around times
- Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
- Communicates determinations to members and providers in compliance with state, federal and accreditation requirements
- Ensures proper procedure codes and diagnosis codes are reviewed for submitted procedures/claims appeal
- Initates referrals for members to Case Management as needs are identified
Your Knowledge and Experience
- Requires a bachelor's degree or equivalent experience
- Requires a current California RN License
- Requires at least 5 years of prior relevant experience
- Proficient skills with Microsoft Office Suite
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Knowledge of Medical policy and benefit reviews
- Demonstrate the ability to act independently using sound clinical judgement
- Solid communication skills
Pay Range:
The pay range for this role is: $ 87230.00 to $ 130900.00 for California.
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's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
#LI-MM4