Appeals and Grievances - RN, Senior

The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievancesthatare theresultof eitherapreservice,post-service or claimdenial. The Medicare Appeals and Grievances RN Senior will report to Utilization Management Nurse Managerfor Medi-Cal and Medicare Appeals and Grievances. In this role,youwill performaccurate and timely clinical review of provider or member appeals, or appeals initiated by someone qualified to speak on behalfofthe member.TheRN performs redetermination appeal reviews for members utilizingCMS 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. Responsibilities

Your Work In this role, you will: Assist review of clinical documentation with case prep regarding member appeals Manage caseload that adheres to regulatory compliance requirements Process clinical oversight review of grievances for dual-eligible members Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination Communicate determinations to theproviders and/or membersin compliance with state, federal and accreditation requirements Ensure proper procedure codes, diagnosis codes, drug names and dosages are reviewed for submitted procedures/service claims/pharmacy appeal Initiates appropriate referrals for members’ needs to other departments such as Case Management. Work collaboratively with business partners, including vendors, to ensure compliance and performance expectations are met Qualifications

Your Knowledge and Experience Bachelor of Science in Nursing or advanced degree preferred Requires a current CA RN License Requires at least 5 years of prior experience in nursing, healthcare or other related fields Knowledge of Medicare, CMS and health plan benefit reviews Knowledge of CPT, ICD-10, HCPCS and billing practices Demonstrate the ability to act independently using sound clinical judgement Knowledge of 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 strongly preferred Job Info

Job Identification 20260054 Job Category Customer Services and Operations Posting Date 01/13/2026, 06:07 PM Apply Before 01/23/2026, 08:00 AM Job Schedule Full time Locations El Dorado Hills, CA, United States CA, United States Long Beach, CA, United States Lodi, CA, United States Oakland, CA, United States Rancho Cordova, CA, United States Redding, CA, United States San Diego, CA, United States Woodland Hills, CA, United States Pay Range for California $90860.00 to $136290.00 Pay Range for Bay Area $102424.00 to $153636.00 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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles. Role can be filled by a candidate requiring sponsorship No

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