Your Role

The Medi-Cal Post Service Review team is responsible for clinically reviewing claims that are the result of either a preservice or claim denial. The Medi-Cal Post Service Review RN will report to the Manager, Post Service. In this role you will perform accurate and timely clinical review of post service claims. The RNs perform reviews 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 inpatient and outpatient Medi-Cal post service cases for benefits, medical necessity, coding accuracy and medical policy compliance..

Your Work

In this role, you will:

• Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination if needed
• 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 claims match the services that were performed
• Initiates appropriate referrals for member’s needs to other departments such as Case Management, Potential Quality Issues (PQI), etc.
• Triages and prioritizes their caseload to meet required regulatory turn-around times

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
• Knowledge of Medicare, Medi-Cal and benefit reviews
• Knowledge of CPT, ICD-10, HCPCS and billing practices
• Demonstrate the ability to act independently using sound clinical judgement

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

About the Company:
Blue Shield of California