<p>Your Role</p> <p>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.</p> <p>Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.</p>