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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 Lead will report to the Appeals and Grievances Manager. 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 experience, hold an active CA license from Board of Registered Nurses and higher-level certifications are highly desirable.

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.

In this role, you will:

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and Med-Cal, including dual-eligibility products.
• Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.
• Prepare and present appeal and grievance cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
• Lead duties for the team including: managing day to day activities of the team, inventory management, spot audits and monthly internal quality review audits, motivating the team to achieve the organizational goals, facilitating clinical rounds and conducting team training as appropriate.
• Stay current and comply with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensure all certifications and/or licenses are up-to-date and valid prior to expiration date.
• Serve as a subject matter expert to aid in identification of Quality-of-Care concerns, possess comprehensive knowledge of benefits utilized to submit review decisions, and apply clinical judgment when assessing services or determining delays that are clinically appropriate.
• Work collaboratively with business partners, including vendors, to assure performance expectations are being met.
• Clearly communicate, be collaborative while working effectively and efficiently.
• Be responsible for inventory management, documentation, training, compliance and identifying areas of process improvement.
• Represent the team at cross-functional meetings and be a point of contact for escalations.

In this role, you will need:

• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• Requires independent motivation, a strong work ethic, and strong computer navigation skills
• Requires familiarity with electronic health record (EHR) systems
• At least 2 years of Supervisory and/or leadership experience preferred
• General knowledge of claims processing logic/rules
• Comprehensive knowledge of Medicare required
• Comprehensive knowledge of health plan operations, regulatory agencies and state/federal regulations related to health care.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business need.