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.
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:
2. Communication of Appeals Process
3. Professional Development
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.
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.
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: 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.
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