CareFirst Careers

Clinical Appeal Nurse Analyst

Resp & Qualifications

PURPOSE: The Clinical Appeals Nurse Analyst completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions under the guidance of a Senior or Lead Clinical Appeals Nurse Analyst. This includes interpretation and application of Clinical Appeals and Analysis departmental policies, corporate policies, submitted clinical information, member and provider contracts, Maryland, Virginia, District of Columbia and Federal regulations and mandates, medical policies, national accreditation requirements and clinical judgment.  Completes the Internal appeal and grievance process and, if applicable, the Regulatory process for appeals and grievances through investigating, interpreting and analyzing clinical information, which includes identifying and taking action to minimize risk to CareFirst.  The Appeals Nurse Analyst uses clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process in order to formulate a professional response to the appeal request. The response may be sent to members, providers, attorneys, external regulatory agencies (i.e. Maryland Insurance Administration, Virginia Bureau of Insurance, District of Columbia Office of Health Care Ombudsman, and Office of Personnel Management), and any other appellants. 

PRINCIPAL ACCOUNTABILITIES:
Under the guidance and supervision of Management and Lead Appeals Nurse Analysts of the Clinical Appeals and Analysis Unit, principal accountabilities include, but are not limited to the following:

1. Appeals Process
Investigates, interprets, and analyzes written appeals and grievances (and reconsiderations), and subsequent correspondence and telephone calls from applicants, subscribers, attorneys, group administrators and any other initiators of appeals and grievances, including in-house staff.  Responsible for directly responding to such appeals and grievances with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.   Routinely uses the following resources to determine outcomes:

  • Investigates, interprets and analyzes multiple communication systems (i.e. CSW, FACETS Task Notes, iCentric), to determine if further clinical information is required to complete the evaluation of the appeal or grievance.
  • Investigates, interprets and analyzes using nursing expert knowledge and all available clinical information, including operative, laboratory, radiology and pathology reports, consultations and clinical progress notes, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate.
  • Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate.
  • Investigates, interprets and analyzes contract information, including individual, group, and provider contract language to determine if adverse coverage decisions are appropriate.
  • Investigates, interprets and analyzes claim information, including BlueCard home plan and ITS processing, NASCO, FACETS Medical and Dental and FEP systems, to determine if adverse coverage decisions are appropriate.
  • Investigates and prepares the file for the External review process for all self-insured, non-Grandfathered groups, according to PPACA regulations.

2. Communication of Appeals Process

  • Organizes the Internal appeal and grievance cases for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. 
  • Investigates and analyzes the information and formulates recommendations for disposition. 
  • Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers with original letters, complex and technical in nature, including explanation of the final decision and all External appeal rights. 
  • Interacts and responds to complaints from Regulatory Agencies.
  • Professional written and verbal communication with external customers including Members, Subscribers, Applicants,  Insurance Brokers, Group Administrators, Regulatory Agencies, Hospital and Physician providers, and vendors.

3. Professional Development

  • Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.
  • Performs any other duties as assigned by Management; i.e.: committee work, special projects, assisting new associates.

SCOPE DATA: Accountable for assisting the Management team in ensuring the integrity of the corporate appeal process at all levels, for all lines of business.  Analytical process validates corporate policies and decisions.  Failure to properly identify, investigate and process disputed issues according to established corporate policies and procedures, as well as State and Federal regulations and mandates, will result in corporate non-compliance with external regulatory review agencies and decrease member and provider satisfaction and impact NCQA accreditation.

QUALIFICATION REQUIREMENTS:
Required: Registered Nurse licensed to practice in Maryland with a minimum of 3-5 years medical-surgical or similar clinical experience. A minimum of 2 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred. 

Abilities/skills:

  • Position requires excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis. Thorough knowledge of current standards of medical practice and insurance benefit structures. 
  • Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable 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 customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  • Must be able to evaluate demands on time and establish and manage appropriate priorities.
  • Must be able to respond with minimal supervisory input due to the nature of the call, requiring quick action. 
  • 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. 
  • Must maintain awareness of current legislation that impacts the appeal & grievance process.
  • Working knowledge of mainframe systems in order to access relevant information necessary for the review process and proficiency with Microsoft Word, Excel, LotusNotes, and various CareFirst dedicated software programs preferred.

Preferred: 

  • BSN/MSN Degree or degree in related field
  • Certified Case Manager (CCM)
  • Legal Nurse Consultant Certified (LNCC) certification

Department

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

Closing Date

Please apply before: 2/28/2019

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 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

Learn more about Medical Management