Appeals and Grievances - RN, Consultant

Your Work 

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. 

Your Knowledge and Experience 

• 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 health plan operations, regulatory agencies and state/federal regulations related to health care.

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. 

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. 

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.