Clinical Appeals Nurse (Remote) ID-1304

Resp & Qualifications


PURPOSE:


The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Government Programs lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.


ESSENTIAL FUNCTIONS:


- Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.


- Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.


- Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accredidation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS.


- Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.


QUALIFICATIONS:


Education Level: High School Diploma or GED.
Licenses/Certifications:
- RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
- CCM - Certified Case Manager Upon Hire Preferred
- LNCC - Legal Nurse Consultant Certified Upon Hire Preferred
Experience: 2 years medical-surgical or similar clinical experience OR 3 years' experience in mental health, psychiatric setting.


Preferred Qualifications:


- 2 years' experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred.
- BSN/MSN Degree. Government Program experience with Appeals and Grievance, Experience with MCG, InterQual, NCD and LCD's.
Knowledge, Skills and Abilities (KSAs)


- Knowledge and understanding of medical terminology.
- Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
- Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task.


- Ability to effectively communicate and provide positive customer service to every internal and external customer.
- Knowledge of Microsoft Office programs.

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PHYSICAL DEMANDS:


The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.


Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship

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