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Registered Nurse Senior

2 months ago

Rancho Cordova, United States Aditi Consulting Full time

Summary:

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 members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG.

 

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.

 

Responsibilities:

·       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.

 

Knowledge and Experience:

·       Requires a current CA RN License

·       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

 

Values:

·       Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short

·       Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes

·       Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals

 

 

Compensation:

The pay rate range above is the base hourly pay range that Aditi Consulting reasonably expects to pay someone for this position (compensation may vary outside of this range depending on several factors, including but not limited to, a candidate’s qualifications, skills, competencies, competencies, competencies, competencies, experience, location and end client requirements).

 

Benefits and Ancillaries:

Medical, dental, vision, PTO benefits and ancillaries may be available for eligible Aditi Consulting employees and vary based on the plan options selected by the employee.