Resp & Qualifications

PURPOSE:
The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider appeals regarding adverse coverage decisions and grievances. 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 Program lines of business to formulate a professional written response to the appeal or grievance request. We are looking for experienced clinicians 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 appeal (reconsideration) and grievance requests from multiple sources including members, authorized representatives, and providers. Responds to such requests in writing letters that are complex and technical in nature, incorporating applicable medical criteria, and upholding corporate policies while meeting all State and Federal regulations and accreditation standards.
• 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, when applicable, communicates the final decision to the members and providers including an explanation of the final decision and all External appeal rights.
• Investigates, interprets, analyzes and prioritizes appeal and grievance 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 accreditation requirements. Collaborates with Independent Review Entities/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: Bachelor of Science in Nursing or related discipline OR in lieu of a bachelor's degree, four (4) years of relevant clinical nursing experience in addition to above experience requirements.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required.
• CCM - Certified Case Manager Upon Hire Preferred.

Experience: Three (3) years of c linically related experience working in Medical Review, Utilization Management, or other RN direct patient care or health insurance payor experience.

Preferred Qualifications:

• Three (3) years Medical Review, Utilization Management, Nurse Auditor/Revenue Integrity, and/or Appeal and Grievance review at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital using MCG or InterQual criteria.
• Certified coder.
• Masters of Science in Nursing or related discipline.

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.
• Excellent analytical and problem-solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $67,320 - $133,705

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

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.

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