Resp & Qualifications
PURPOSE: Supervises, directs and coordinates the accurate implementation of the clinical appeal process for members and providers who appeal on behalf of members for all lines of business, and all Companies within CareFirst, Inc. Incumbent is accountable for ensuring grievance and appeal decisions are accurate based on the member’s health benefit contract and CareFirst Medical Policy and is compliant with State and Federal regulatory requirements. Responsible for the assessment, development, implementation, and evaluation of processes, standards, policies and procedures that result in well organized, effective, and quality resolution to appeals, grievances and reconsiderations from members and providers on behalf of members. Knowledgeable about and acts in accordance with Federal and State laws related to the scope of practice and regarding response to appeals and grievances. Acts as the primary professional source, educator and strategists for communication with all external regulatory review agencies and is responsible for a timely and effective response to complaints. The incumbent directs the activities of the Lead Appeals Nurse Analysts, Senior Appeals Nurse Analysts, Appeals Nurse Analysts, and Appeals Specialists. The incumbent serves as a professional resource for the Clinical Appeals and Analysis Unit, Medical Management, Legal and Legislative Affairs, CareFirst Medical Directors, the Strategic Business Units, as well as Sales and Marketing. Provides oversight and accountability for the coordination of the appeal reviews with Medical Director, Executive Staff, and Legal. The incumbent provides overall accountability for the orientation and training of new Clinical Appeals associates.
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.
SCOPE DATA: Directly accountable for ensuring the integrity of the Corporate appeal process at all levels, for all lines of business. Quality management of the clinical appeal process reduces the risk of State and Federal Regulatory fines and sanctions, avoids adverse exposure, reiterates the expectation of a fair and compliant appeal process for our membership, and supports NCQA accreditation and the Divisional Goals for Care Management. Failure to properly identify, investigate and process disputed issues according to the established corporate policies and procedures, as well as Legislative policies and mandates, will result in corporate non-compliance and decrease member and provider satisfaction.
QUALIFICATION REQUIREMENTS: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
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: 3/25/19
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.
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