Appeals and Grievances - RN, Senior (Behavioral Health)

Your Role

The Member 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 Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of member-initiated appeals or appeals initiated on behalf of members from an authorized representative. The RNs perform first level appeal reviews for members utilizing Milliman Care Guidelines, Member Handbook or Evidence of Coverage, Department of Managed Care (DMHC) guidelines, ASAM, WPATH, ABA, CALOCUS, LOCUS and other nationally recognized professional guidelines such as NCCN, NCQA, DOI, and ACOG. The successful RN candidate will review both inpatient and outpatient member appeals for benefits, medical necessity, coding accuracy and medical policy compliance.

Your Knowledge and Experience

• Requires a current CA RN License
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields with an emphasis on Behavioral Health/Mental Health
• Bachelor of Science in Nursing or Advanced Degree preferred
• Knowledge of Commercial, ASO, Medicare Advantage and benefit reviews with emphasis on Behavioral Health/Mental Health appeals review but not required.
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement with acquired basic computer skillset utilizing programs such as Microsoft, shared drives, TEAMS, PDF etc.