Resp & Qualifications
Under the direction of the Manager of the Clinical Appeals and Analysis Unit, the incumbent’s accountabilities include, but are not limited to, the following:
1. Provides direct supervision for the activities of the Lead Appeals Nurse Analysts, Senior Appeals Nurse Analysts, Appeals Nurse Analysts, and Appeals Specialists, ensuring appropriate and complete resolution of all appeals and grievances, including Regulatory complaints and External review requests. In-direct supervision of the Business Analysts and Operations Coordinator, who perform and support reporting and analysis for the Clinical Appeals and Analysis Unit. Oversight of the research, evaluation and response for complex cases, Overall accountability for quality review and interpretation of the appeal case and accurate communication of the appeal decision, including all applicable External review rights. Responsible for review of contracts and other appropriate documentation with Legal and Legislative Representatives. as needed. Overall responsibility for all written and verbal professional correspondence related to the institutional and professional Appeal and Grievance process, as well as the FEP reconsideration process. Acts as the primary professional resource for the external regulatory review agencies, hospitals, physicians, and customers internal and external to CareFirst with the overall goal of providing and ensuring appropriate and timely response to complaints, appeals and grievances.
2. Oversee the preparation of chronologies of medical events in response to regulatory complaints and/or to assist the Legal Department in preparation for legal disputes. Responsible for conducting research and summarizing medical literature. Educates corporate attorneys regarding medical facts and issues relating to cases or claims payment. In collaboration with the CareFirst Legal Department, responsible for the organization of medical records and other medically related litigation materials. Responsible for research and coordination of research activities within the Clinical Appeals Unit. Accountable for integrating nursing knowledge with insurance litigation in accordance with State and Federal laws. Acts as a liaison with attorneys, physicians and members. Collaborates with attorneys in preparing interrogatories, depositions and trial outlines and documentation production requests.
3. Accountable for the supervision of associates. Assigns tasks according to Associate knowledge, skill sets, experience and development needs. Motivates associates to achieve a high level of performance and establishes a team effort toward meeting and exceeding Corporate and divisional goals and expectations. Development, implementation and evaluation of Performance Plans, providing accurate and timely performance reviews and feedback. Monitors the monthly audits and productivity performance of associates. Largely responsible for development and oversight of the orientation and training of new and current staff, and assessment of training needs. Collaborates with and serves as the primary professional resource for the Lead Appeals Nurse Analysts, Senior Appeals Nurse Analysts, Appeals Nurse Analysts, Appeals Specialists, Medical Review areas, Legal and Legislative Affairs, Strategic Business Units, as well as Sales and Marketing, to interpret medical policy, advise on appeal and grievance procedures or assist with sensitive issues to resolve conflicts with our members.
4. Participates in appropriate and assigned employer group presentations, Provider/Institutional educational meetings, operational meetings and internal and external audits. Supports the Manager of Clinical Appeals and Analysis in the development and presentation of quarterly reviews, compiling statistical performance data and data related to the volume and complexity of the appeals and grievances submitted for resolution.
5. Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the Corporation and potentially impact the overall Corporate and divisional goals.
SUPERVISORY RESPONSIBILITY: The incumbent provides direct supervision of 8-12 Registered Nurses and Appeals Specialists, with complete responsibility for handling personnel issues, including development and improvement plans, disciplinary actions and semi-annual and annual performance reviews. In addition, provides indirect supervision of additional 33-37 Registered Nurses, Appeals Specialists, Business Analysts and Operations Coordinator.
Required: The incumbent must be a registered nurse with licensure in the State of Maryland and a minimum of 5-10 years of clinical experience and a minimum of 5 years experience in Medical Review, Utilization Management or Care Management at CareFirst or other managed care entity. Supervisory experience or progressive responsibility/leadership experience
Abilities/skills: Excellent analytical and problem solving skills are needed to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis. The incumbent should have thorough knowledge of current standards of medical practice and insurance benefit structures. The ability to evaluate, interpret and apply established policies and federal and state laws, resulting in an outcome that is congruent with the Corporate and divisional standards and regulatory mandates. Position requires excellent communication skills, which includes verbal and written abilities in order to communicate effectively with internal and external customers. The incumbent should have strong public speaking skills. Many contacts regarding appeals are confrontational in nature and require tact and strong problem solving abilities. This position requires the ability to resolve difficult situations independently, due to the nature of the quick responses needed to members, attorneys, physicians, hospitals and other providers. Must have ability to build and maintain key relationships in the community. Strong interpersonal communication skills, with a specific focus on coaching, training, and staff development. The incumbent must maintain a ready command of a continuously expanding knowledge base of current medical and psychiatric practices and procedures, including current medical procedural terminology, surgical procedures, diagnostic entities and their complications. They must also maintain awareness of current legislation that impacts the appeal and grievance process.
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that may be sustained for long periods of time. 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.
Preferred: Three years of supervisory experience, managing 10+ exempt and non-exempt Associates. BS/MSN Degree, or related field, and Certified Case Manager (CCM) or Legal Nurse Consultant Certified (LNCC) certification.
Department: Clinical Appeals and Analysis
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/16/18
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee 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 employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship