A & G Resolution Nurse

Capital Blue Cross•Harrisburg, PA

About The Position

The A & G Resolution Nurse supports the Plan by resolving complex clinical complaints, grievances, and appeals. The role reviews documentation and interprets clinical records, applying appropriate clinical criteria and policies in accordance with regulatory and accreditation requirements for member and provider issues. The nurse independently coordinates clinical resolutions, obtaining internal or external clinician support as needed, and documents and communicates results to all parties involved. The position provides complex clinical support for corporate, departmental, and special projects related to Complaints, Grievances, and Appeals. It analyzes clinical issues involving policies, procedures, and contracts; recommends improvements or revisions; and follows up to ensure changes are implemented and supporting documentation is updated. The nurse may serve as a department liaison for cases requiring legal recommendations and provides clinical guidance to Plan personnel in accordance with applicable guidelines and performance measures. Additional duties may include peer reviews, audit support, desk mentoring, and functional training. The incumbent also provides rotating on-call weekend and holiday coverage. Capital Blue Cross describes a flexible, supportive work environment and offers benefits including medical, dental, and vision coverage, a retirement plan, paid time off, holidays, volunteer time off, an incentive plan, and tuition reimbursement.

Requirements

Bachelor’s degree is required.
RN certification is required.
At least 5 years of clinical experience.
Working knowledge of Medicare C and D.
Ability to interact with other departments to advise, educate, or direct members to appropriate services.
Demonstrated analytical, research, and organizational skills to identify and analyze trends, discrepancies, and issues involving Plan policies, procedures, and contracts.
Demonstrated verbal communication skills, including the ability to present opinions and research findings to management.
Demonstrated written communication skills, including the ability to produce clear, thorough, and detailed letters, memos, and reports on complex subject matter.
Demonstrated project management skills and the ability to manage multiple assignments, adjust to changing priorities, and work independently.
Familiarity with Microsoft Office Suite.
Knowledge of URAC and NCQA standards for case management organizations and CMSA Standards of Practice for Complaints, Appeals, and Grievances.
Knowledge of managed care principles and emerging health treatment modalities.
Ability to operate a personal computer and proficiency in Word, Access, Excel, Outlook, and clinical databases using talk-and-type documentation.

Responsibilities

Resolve complex clinical complaints, grievances, and appeals by reviewing documentation and interpreting clinical records.
Apply clinical criteria and policies consistent with regulatory and accreditation requirements for member and provider issues.
Coordinate clinical resolutions independently, obtaining internal or external clinician support as required.
Document and summarize case results for all parties involved.
Provide complex clinical support for corporate, departmental, and special projects related to Complaints, Grievances, and Appeals.
Draft recommendations concerning issues affecting Complaints, Grievances, and Appeals, and communicate solutions.
Identify, review, and analyze complex clinical issues involving corporate policies and procedures.
Contact Management, Government Programs, and external contacts to discuss questions and issues.
Recommend improvements, updates, or clarifications to policies and procedures, and follow up to ensure changes are implemented.
Request or initiate revisions to supporting documentation, such as policy manuals, procedure manuals, and bulletins.
Serve as a department liaison for cases or issues requiring legal recommendations and direction.
Provide clinical reference and guidance to Plan personnel concerning inquiry resolution under applicable guidelines and performance measures.
Recommend or take action to improve service through interaction with other Plan personnel.
Conduct peer reviews and document findings as assigned.
Provide audit support.
Mentor new staff and staff undergoing cross-training, and provide functional training for peers as workload requires.
Provide rotating on-call weekend and holiday coverage.