Appeals and Grievances - RN, Senior- Medicare

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 Utilization Management Nurse Manager 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 etc