Appeals and Grievances - RN, Consultant

Your Role

The Medicare and Medical 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 Lead will report to the Appeals and Grievances Manger. In this role you will be leading a team of nurses who will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate will have previous leadership experienced, hold at least a Bachelor's Degree in Nursing and higher-level certifications are highly desirable.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Requires familiarity with electronic health record (EHR) systems
• At least 2 years of Supervisory and/or leadership experience preferred

Pay Range:

The pay range for this role is: $ 109340.00 to $ 164120.00 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.