Resp & Qualifications
PURPOSE: This position handles day to day reviews and processes and/or adjudicates complex professional and institutional claims and inquiries that require individual consideration, medical necessity, or medical appropriateness review for proper adjudication for claims processing. The position assists the Corporation in determining acceptable medical risk to Corporation by analyzing medical information of applicants for enrollment in specific policies. The incumbent prepares, on behalf of the Corporation, appropriate correspondence to applicants, members, attorneys, or other designees as well as Insurance Commissioners. Must be able to use multiple claims and enrollment systems as well as applicable systems to manage and track utilization. Uses software to perform research and eligibility checks. Senior Clinical Review Specialist acts as the Subject Matter Expert for Clinical Review Specialist, Claims Review Analyst, Medical Management areas, Legal and Legislative Affairs, Medical Directors, all Administrative Service Units and Sales regarding the Clinical Medical Review process. Acts as a primary professional resource for orientation and training of new associates and development of training materials and resources.
PRINCIPAL ACCOUNTABILITIES Medical Review Focus:
Receive, research, review and analyze professional and institutional claims and customer inquiries that require medical expertise and knowledge for proper processing and/or adjudication. Review claims for medical appropriateness, proper billing, medical necessity, pre-existing, cosmetic, experimental/investigational, compliance with health care policy, Carefirst BCBS coding guidelines and contract benefits within timeframes established by the accounts, the department and Operations and authorizations. This includes interpreting and analyzing medical information such as, operative, laboratory, radiology and pathology reports, consultations, and medical progress notes to determine applicability of benefits. Prepares cases as necessary for physicians in community in which their expertise is required. Interpret contract language and benefit structure as necessary. Prepare denial letters to all appropriate parties within the department time frames describing the reason or criteria used for denial. Refers appropriate cases to Quality Improvement and/or Special Investigations.
Assist with pricing of procedure codes which require individual consideration or are listed as “not otherwise classified” in CPT manual. Must be able to interpret medical information and make comparison to similar or like procedures.
Acts as mentor to new associates or existing associates being cross trained on different functions.
Handles non complex projects as assigned by Lead CRS or Supervisor, completing assignment within a specific timeframe with specific goals.
Participates in medical policy meetings, nurses forums, review sessions with Medical and Dental directors, special projects, task forces, committees as assigned. Assists in development and communication of health care policy or Corporate Medical Underwriting criteria changes. Makes recommendations on existing and new policies. Participates in continuing education and staff development programs. Participates in departmental quality improvement as well as department/team enhancement activities.
SUPERVISORY RESPONSIBILITY: This job does not have Supervisory responsibilities. This job acts as a Subject Matter Expert (SME) and training resource.
Required: The incumbent must be a licensed, registered nurse with a college degree or Nursing diploma. Must have 5 years of acute clinical experience, previous case management, discharge planning or utilization review experience. Must consistently meet or exceed goals established for section.
Abilities/skills: The incumbent must be self-directed with an ability to work independently. Must have excellent oral and written communication skills as well as organizational and problem-solving skills. Must be able to analyze information and make complex decisions or recommendations based upon Corporate or department policies. Must be able to formulate medical responses for service areas to assist with decision notifications. Must have PC skills in Word, Excel, and data entry into databases.
Department: FEP MD Nurse Review
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: 6/18/21
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
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