Home › Companies › Ecge Fa Us2 Oraclecloud Com CX 1003 › Appeals and Grievances - RN, Consultant (Medicare)
Appeals and Grievances - RN, Consultant (Medicare)
Ecge Fa Us2 Oraclecloud Com CX 1003 · Rancho Cordova, CA, United States; US-CA-Long Beach-Kilroy Airport · Hybrid · Active · Oracle Recruiting Cloud / Fusion HCM
Job facts
| Field | Value |
|---|---|
| Company | Ecge Fa Us2 Oraclecloud Com CX 1003 |
| Title | Appeals and Grievances - RN, Consultant (Medicare) |
| Normalized title | - |
| Department / team | Customer Services and Operations |
| Location | Rancho Cordova, CA, United States |
| Work model | Hybrid / Hybrid |
| Employment type | Full Time |
| Salary | - |
| Status | active |
| ATS provider | Oracle Recruiting Cloud / Fusion HCM |
| Posted / first seen | 2026-05-01 / 2026-05-31 |
| Changed / last seen | 2026-05-31 / 2026-06-06 |
Related slices
| Page | What it contains | Open |
|---|---|---|
| Company jobs | Active postings from Ecge Fa Us2 Oraclecloud Com CX 1003. | Open |
| Company breakdowns | Role, location, ATS, and work model facets for this company. | Open |
| ATS provider jobs | Active postings observed through Oracle Recruiting Cloud / Fusion HCM. | Open |
| Provider filtered search | The same provider as a filtered job collection. | Open |
| City jobs | Active postings in Rancho Cordova. | Open |
| Department jobs | Active postings in Customer Services and Operations. | Open |
| Work model jobs | Active Hybrid postings. | Open |
| Lifecycle events | Open, update, close, and reopen events for this posting. | Open |
| Original posting | Canonical source or apply URL captured from the ATS. | Open |
Linked records
| Company | Ecge Fa Us2 Oraclecloud Com CX 1003 |
| Source | 2426c13c-5fb6-4954-b4fc-d0476cec17ee |
| ATS provider | Oracle Recruiting Cloud / Fusion HCM |
Description
Description
Your Role
The Medicare 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 Medicare Appeals and Grievances RN Lead will report to the Appeals and Grievances Manger. In this role you will be leading a team of nurses who will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate will have previous leadership experience, hold an active CA license from Board of Registered Nurses and higher-level certifications are highly desirable.
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.
Responsibilities
Your Work
In this role, you will:
Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and Med-Cal, including dual-eligibility products.
Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.
Prepare and present appeal and grievance cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
Lead duties for the team including: managing day to day activities of the team, inventory management, spot audits and monthly internal quality review audits, motivating the team to achieve the organizational goals, facilitating clinical rounds and conducting team training as appropriate.
Stay current and comply with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensure all certifications and/or licenses are up-to-date and valid prior to expiration date.
Serve as a subject matter expert to aid in identification of Quality-of-Care concerns, possess comprehensive knowledge of benefits utilized to submit review decisions, and apply clinical judgment when assessing services or determining delays that are clinically appropriate.
Work collaboratively with business partners, including vendors, to assure performance expectations are being met.
Clearly communicate, be collaborative while working effectively and efficiently.
Be responsible for inventory management, documentation, training, compliance and identifying areas of process improvement.
Represent the team at cross-functional meetings and be a point of contact for escalations.
Qualifications
Your Knowledge and Experience
Bachelor of Science in Nursing or advanced degree preferred
Requires a current California RN License
Requires at least 7 years of prior relevant experience
Requires independent motivation, a strong work ethic, and strong computer navigation skills Requires familiarity with electronic health record (EHR) systems At least 2 years of Supervisory and/or leadership experience preferred
General knowledge of claims processing logic/rules
Comprehensive knowledge of Medicare required
Comprehensive knowledge of health plan operations, regulatory agencies and state/federal regulations related to health care.
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business need.
Organization
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
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 listen and communicate effectively, showing empathy by understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
For most teams, this means coming into the office two days per week.
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Full job record
| Job ID | 89c74b91dd231ba3e9e56777d00440e777b869dc |
| Org ID | 202edd25-dd99-459f-9155-82b80529e892 |
| Source ID | 2426c13c-5fb6-4954-b4fc-d0476cec17ee |
| Board ID | 2426c13c-5fb6-4954-b4fc-d0476cec17ee |
| Provider | oracle_hcm |
| Provider Job Key | 20260774 |
| Title | Appeals and Grievances - RN, Consultant (Medicare) |
| Normalized Title | — |
| Status | active |
| Active | yes |
| Location Text | Rancho Cordova, CA, United States; US-CA-Long Beach-Kilroy Airport |
| Department | Customer Services and Operations |
| Team | — |
| Employment Type | full_time |
| Workplace Type | hybrid |
| Remote Policy | hybrid |
| Country | United States |
| Region | CA |
| City | Rancho Cordova |
| Salary Raw | Description Your Role The Medicare 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 Medicare Appeals and Grievances RN Lead will report to the Appeals and Grievances Manger. In this role you will be leading a team of nurses who will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate will have previous leadership experience, hold an active CA license from Board of Registered Nurses and higher-level certifications are highly desirable. 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. Responsibilities Your Work In this role, you will: Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and Med-Cal, including dual-eligibility products. Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance. Prepare and present appeal and grievance cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements. Lead duties for the team including: managing day to day activities of the team, inventory management, spot audits and monthly internal quality review audits, motivating the team to achieve the organizational goals, facilitating clinical rounds and conducting team training as appropriate. Stay current and comply with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensure all certifications and/or licenses are up-to-date and valid prior to expiration date. Serve as a subject matter expert to aid in identification of Quality-of-Care concerns, possess comprehensive knowledge of benefits utilized to submit review decisions, and apply clinical judgment when assessing services or determining delays that are clinically appropriate. Work collaboratively with business partners, including vendors, to assure performance expectations are being met. Clearly communicate, be collaborative while working effectively and efficiently. Be responsible for inventory management, documentation, training, compliance and identifying areas of process improvement. Represent the team at cross-functional meetings and be a point of contact for escalations. Qualifications Your Knowledge and Experience Bachelor of Science in Nursing or advanced degree preferred Requires a current California RN License Requires at least 7 years of prior relevant experience Requires independent motivation, a strong work ethic, and strong computer navigation skills Requires familiarity with electronic health record (EHR) systems At least 2 years of Supervisory and/or leadership experience preferred General knowledge of claims processing logic/rules Comprehensive knowledge of Medicare required Comprehensive knowledge of health plan operations, regulatory agencies and state/federal regulations related to health care. Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business need. Organization About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us! 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 listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail. Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws. |
| Salary Min | — |
| Salary Max | — |
| Salary Currency | — |
| Salary Period | day |
| Source URL | https://ecge.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_1003/job/20260774 |
| Apply URL | https://ecge.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_1003/job/20260774 |
| First Seen At | 2026-05-31 17:55:51Z |
| Last Seen At | 2026-06-06 19:41:05Z |
| Last Checked At | 2026-06-06 19:41:05Z |
| Last Changed At | 2026-05-31 17:55:51Z |
| Inactive At | — |
| Source Posted At | 2026-05-01 18:19:14Z |
| Source Updated At | — |
| Raw Payload Uri | s3://job-postings-prod-raw-590183727216/raw/provider=oracle_hcm/board=ecge.fa.us2.oraclecloud.com|CX_1003/date=2026-06-06/2026-06-06T19-40-51-331Z-3651ec34c6b82d2393faf29dc23b074f87ef1ed2ccc426b00005dad9b6bd6573.json |
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"OrganizationDescriptionStr": "<p style=\"margin:12pt 0in 0in\"></p>\n<p><b>About Blue Shield of California</b></p>\n<p>As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. </p>\n<p>At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. </p>\n<p>To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.</p>\n<p>Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us! </p>\n<p><b>Our Values: </b></p>\n<p style=\"margin-left:0.25in\"></p>\n<ul>\n <li><b>Honest. </b>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.<b> </b><b></b></li>\n <li><b>Human. </b>We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.</li>\n <li><b>Courageous. </b>We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.<b> </b></li>\n</ul>\n<div>\n <p><b>Our Workplace Model</b> </p>\n <p>We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:</p>\n <ul>\n <li>\n <p>For most teams, this means coming into the office two days per week.</p></li>\n <li>\n <p>Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.</p></li>\n <li>\n <p>For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.</p></li>\n </ul>\n <p>The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. </p>\n <p></p>\n</div>\n<div>\n</div>\n<ul></ul>\n<p><b>Physical Requirements:</b></p>\n<p>Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.</p>\n<p><a href=\"https://www.blueshieldca.com/physical-job-requirements\" target=\"_blank\" rel=\"nofollow\">Please click here for further physical requirement detail.</a> </p>\n<p><b>Equal Employment Opportunity:</b></p>\n<p>External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.</p>",
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"ShortDescriptionStr": "The Medicare 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 Medicare Appeals and Grievances RN Lead will report to the Appeals and Grievances Manger. In this role you will be leading a team of nurses who will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for quality audits, inventory management and reviews of department work process documents. The ideal candidate will have previous leadership experience, hold an active CA license from Board of Registered Nurses and higher-level certifications are highly desirable. ",
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