Current jobs related to Appeals and Grievances - Rancho Cordova - Blue Shield of California
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Appeals and Grievances
4 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
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Appeals and Grievances
3 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe 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...
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Appeals and Grievances
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe 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...
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Appeals and Grievances
3 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
3 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
1 week ago
Rancho Cordova, 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...
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Appeals and Grievances
4 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
3 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
4 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
4 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
3 weeks ago
Rancho Cordova, 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleBelow covers everything you need to know about what this opportunity entails, as well as what is expected from applicants.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...
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Clinical Appeals and Grievances Specialist
2 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour Role:As a Clinical Appeals and Grievances Specialist at Blue Shield of California, you will be responsible for reviewing member appeals and grievances related to Medicare and Medi-Cal benefits. This role requires a strong understanding of clinical guidelines, including National Coverage Determination (NCD) and Local Coverage Determination (LCD)...
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Appeals and Grievances Clinical Reviewer
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Appeals and Grievances team at Blue Shield of California is seeking a skilled RN Senior to join our team. As a Clinical Reviewer, you will play a critical role in ensuring that member appeals and grievances are handled in a timely and accurate manner.Key ResponsibilitiesConduct thorough clinical reviews of member-initiated appeals and...
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Appeals and Grievances
2 weeks ago
Rancho Cordova, CA, 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
2 months 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
Initiates referrals for members to Case Management as needs are identified
Your Knowledge and ExperienceBachelors of Science in Nursing or advanced degree preferred.Requires a current California RN License Requires at least 5 years of prior relevant experienceProficient skills with Microsoft Office SuiteKnowledge of CPT, ICD-10, HCPCS and billing practicesKnowledge of Medical policy and benefit reviews preferredDemonstrate the ability to act independently using sound clinical judgementRequires advanced knowledge of appeals and grievances typically obtained through advanced education combined with experience. Solid communication skillsPay 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-RU1
