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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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