Program Manager Clinical, Principal
Company: Blue Shield of California
Location: Woodland
Posted on: June 14, 2022
Job Description:
Description - ExternalBlue Shield of California's mission is to
ensure all Californians have access to high-quality health care at
a sustainably affordable price. We are transforming health care in
a way that truly serves our nonprofit mission by lowering costs,
improving quality, and enhancing the member and physician
experience. To fulfill our mission, we must ensure a diverse,
equitable, and inclusive environment where all employees can be
their authentic selves and fully contribute to meet the needs of
the multifaceted communities we serve. Our comprehensive approach
to diversity, equity, and inclusion combines a focus on our people,
processes, and systems with a deep commitment to promoting social
justice and health equity through our products, business practices,
and presence as a corporate citizen. Blue Shield has received
awards and recognition for being a certified Great Place to Work,
best place to work for LGBTQ equality, leading disability employer,
one of the best companies for women to advance, Bay Area's top
companies in volunteering & giving, and one of the world's most
ethical companies. Here at Blue Shield of California, we are
striving to make a positive change across our industry and the
communities we live in - join us! Your RoleThe Medi-Cal 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 Medi-Cal Appeals and Grievances
RN Senior will report to Tracey Benson, the Senior RN Manager,
Medi-Cal Appeals and Grievances. In this role you will perform
accurate and timely clinical review of member-initiated appeals or
appeals initiated by someone qualified to speak on behalf of the
member. The RN perform first level appeal reviews for members
utilizing the National Coverage Determination (NCD) guidelines,
Local Coverage Determination (LCD) Guidelines, DHCS Medi-Cal
Guidelines, Milliman Care Guidelines, and nationally recognized
sources such as NCCN and ACOG. The successful RN candidate will
review both medical and pharmacy Medi-Cal member appeals for
benefits, medical necessity, coding accuracy and medical policy
compliance. Your WorkIn this role, you will:
- Assist with telephone inquiries regarding member appeals
- Identify issues, and with assistance, execute corrective
action
- Intake Queue
- Process clinical oversight review of grievances
- Triages and prioritizes cases to meet required regulatory
turn-around times
- Prepares and submits clinical case reviews to the Medical
Director (MD) for MD collaboration and medical necessity
determination
- Communicates determinations to the members and providers in
compliance with state, federal and accreditation requirements
- Ensures proper procedure codes and diagnosis codes are reviewed
for submitted procedures/claims appeal
- Initiates appropriate referrals for member's needs to other
departments such as Case Management. Qualifications - ExternalYour
Knowledge and Experience
- Requires a high school diploma or GED
- 0-2 years of prior relevant experience
- Current CA RN License
- Behavioral Health Experience Preferred
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Knowledge of Medi-Cal and benefit reviews
- Demonstrate the ability to act independently using sound
clinical judgement
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 be our authentic selves, listening and
communicating effectively, and showing empathy towards others by
walking in their shoes
- Courageous. We stand up for what we believe in and are
committed to the hard work necessary to achieve our ambitious goals
Internal DescriptionDescription - InternalBlue Shield of
California's mission is to ensure all Californians have access to
high-quality health care at a sustainably affordable price. We are
transforming health care in a way that truly serves our nonprofit
mission by lowering costs, improving quality, and enhancing the
member and physician experience. To fulfill our mission, we must
ensure a diverse, equitable, and inclusive environment where all
employees can be their authentic selves and fully contribute to
meet the needs of the multifaceted communities we serve. Our
comprehensive approach to diversity, equity, and inclusion combines
a focus on our people, processes, and systems with a deep
commitment to promoting social justice and health equity through
our products, business practices, and presence as a corporate
citizen. Blue Shield has received awards and recognition for being
a certified Great Place to Work, best place to work for LGBTQ
equality, leading disability employer, one of the best companies
for women to advance, Bay Area's top companies in volunteering &
giving, and one of the world's most ethical companies. Here at Blue
Shield of California, we are striving to make a positive change
across our industry and the communities we live in - join us! Your
RoleThe Medi-Cal 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
Medi-Cal Appeals and Grievances RN Senior will report to Tracey
Benson, the Senior RN Manager, Medi-Cal Appeals and Grievances. In
this role you will perform accurate and timely clinical review of
member-initiated appeals or appeals initiated by someone qualified
to speak on behalf of the member. The RN perform first level appeal
reviews for members utilizing the National Coverage Determination
(NCD) guidelines, Local Coverage Determination (LCD) Guidelines,
DHCS Medi-Cal Guidelines, Milliman Care Guidelines, and nationally
recognized sources such as NCCN and ACOG. The successful RN
candidate will review both medical and pharmacy Medi-Cal member
appeals for benefits, medical necessity, coding accuracy and
medical policy compliance. Your WorkIn this role, you will:
- Assist with telephone inquiries regarding member appeals
- Identify issues, and with assistance, execute corrective
action
- Intake Queue
- Process clinical oversight review of grievances
- Triages and prioritizes cases to meet required regulatory
turn-around times
- Prepares and submits clinical case reviews to the Medical
Director (MD) for MD collaboration and medical necessity
determination
- Communicates determinations to the members and providers in
compliance with state, federal and accreditation requirements
- Ensures proper procedure codes and diagnosis codes are reviewed
for submitted procedures/claims appeal
- Initiates appropriate referrals for member's needs to other
departments such as Case Management. Qualifications - InternalYour
Knowledge and Experience
- Requires a high school diploma or GED
- 0-2 years of prior relevant experience
- Current CA RN License
- Behavioral Health Experience Preferred
- Knowledge of CPT, ICD-10, HCPCS and billing practices
- Knowledge of Medi-Cal and benefit reviews
- Demonstrate the ability to act independently using sound
clinical judgement
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 be our authentic selves, listening and
communicating effectively, and showing empathy towards others by
walking in their shoes
- Courageous. We stand up for what we believe in and are
committed to the hard work necessary to achieve our ambitious
goals
Keywords: Blue Shield of California, Woodland , Program Manager Clinical, Principal, Education / Teaching , Woodland, California
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