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:
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:
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.
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.
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: 10/16/2019
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, organize paperwork, key and handle or feel small controls and objects. The employee must have good visual acuity for computer viewing and must frequently talk and hear. Weights of up to 10 pounds are occasionally lifted. Travel among CareFirst sites and to legal hearing sites may be necessary.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship