Appeals and Grievances - RN, Senior

Blue Shield of California • El Dorado Hills, CA

3d • Hybrid

About The Position

Your Role

The Medicare 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 Medicare Appeals and
Grievances RN Senior will report to the Manager of Utilization Management for
Medi-Cal and Medicare Appeals and Grievances. In this role, you will
perform accurate and timely clinical review of provider or member appeals, or
appeals initiated by someone qualified to speak on behalf of the member. The RN
performs redetermination appeal reviews for members utilizing CMS and/or DHCS
approved guidelines, BSC plan policies and nationally recognized clinical
criteria across lines of business or for a specific line of business such as
Medicare, Medi-Cal, including dual-eligibility products; therefore, the Medicare
Appeals RN has understanding and knowledge of the Medicare Provider Manual,
National Coverage Determination (NCD) guidelines, Local Coverage Determination
(LCD) Guidelines, DHCS Medi-Cal Guidelines, Milliman Care Guidelines (MCG), BSC
Pharmacy Policies, BSC Formularies and nationally recognized sources such as
NCCN and ACOG. The successful RN candidate will review both medical (Medicare
Part B/C) and pharmacy (Medicare Part D) appeals for Medicare/DSNP benefits,
medical necessity, coding accuracy and medical policy compliance, as well as
grievances for clinical issues.

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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun.
Ascendiun is a nonprofit corporate entity that is the parent to a family of
organizations including Blue Shield of California and its subsidiary, Blue
Shield of California Promise Health Plan; Altais, a clinical services company;
and Stellarus, a company designed to scale healthcare solutions. Together, these
organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system
worthy of our family and friends and sustainably affordable. We are transforming
health care in a way that genuinely serves our nonprofit mission by lowering
costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive
and contribute fully to address the needs of the various communities we serve.
We are committed to creating and maintaining a supportive workplace that upholds
our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best
Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360
as a Top Regional Company, and one of the 50 most community-minded companies in
the United States by Points of Light. Here at Blue Shield, we strive to make a
positive change across our industry and communities – join us!  

Our 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 listen and communicate effectively, showing empathy by
understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard
work necessary to achieve our ambitious goals. 

Our Workplace Model 

We believe in fostering a workplace environment that balances purposeful
in-person collaboration with flexibility - providing clear expectations while
respecting the diverse needs of our workforce. Our workplace model is designed
around intentional in-person interaction, collaboration,
connection, creativity and flexibility:

For most teams, this means coming into the office two days per week.

Employees living more than 50 miles from an office location, out of state
employees, and employees in certain member-facing roles should work with
their manager to determine in-office time based on business need.

For employees with medical conditions that may impact their ability to work
in-office, we are committed to engaging in an interactive process and
providing reasonable accommodations to ensure their work environment is
conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on
business needs, and requirements are subject to change with periodic reviews.  

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office
Environment. Based in our physical offices and work from home office/deskwork -
Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.
[https://www.blueshieldca.com/physical-job-requirements] 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants
with arrest records and/or conviction records will be considered for employment
in a manner consistent with Federal, State and local laws, including but not
limited to the San Francisco Fair Chance Ordinance. All qualified applicants
will receive consideration for employment without regards to race, color,
religion, sex, national origin, sexual orientation, gender identity, protected
veteran status or disability status and any other classification protected by
Federal, State and local laws.

Responsibilities

• perform accurate and timely clinical review of provider or member appeals, or appeals initiated by someone qualified to speak on behalf of the member
• performs redetermination appeal reviews for members utilizing CMS and/or DHCS approved guidelines, BSC plan policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare, Medi-Cal, including dual-eligibility products
• review both medical (Medicare Part B/C) and pharmacy (Medicare Part D) appeals for Medicare/DSNP benefits, medical necessity, coding accuracy and medical policy compliance, as well as grievances for clinical issues

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed