A & G Resolution Nurse

Capital Blue Cross•Harrisburg, PA

About The Position

Provides support to the Plan by resolving complex clinical complaints, grievances, and appeals. Reviews documentation and interprets clinical-record data to apply appropriate clinical criteria and policies in accordance with regulatory and accreditation requirements for member and provider issues. Independently coordinates clinical resolutions, involving internal or external clinician support as needed, and documents and summarizes results for the parties involved. The role also provides complex clinical support for corporate, departmental, and special projects relating to Complaints, Grievances, and Appeals. It analyzes clinical issues involving corporate policies and procedures, consults with management and other contacts, recommends improvements, and follows up to ensure policy and procedure changes are implemented. The incumbent serves as a department liaison on cases requiring legal recommendations and provides clinical guidance to Plan personnel on inquiries governed by applicable guidelines and quality measures. Additional duties may include peer reviews, audit support, mentoring and training staff, and rotating on-call weekend and holiday coverage. Capital Blue Cross describes a flexible environment and offers a comprehensive benefits package, professional development, and opportunities to volunteer in the community.

Requirements

Bachelor’s degree required.
RN certification required.
At least 5 years of clinical experience, including working knowledge of Medicare C and D.
Ability to interact with other departments to advise, educate, or direct members to appropriate services.
Analytical, research, and organizational skills to identify and analyze trends, discrepancies, and issues involving Plan policies, procedures, and contracts.
Verbal communication skills to express opinions and research findings to management personnel.
Written communication skills to produce clear, thorough, and detailed letters, memos, and reports on complex subject matter.
Project management skills and ability to manage multiple assignments, adjust to changing priorities, and work independently.
Familiarity with software such as 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 use a personal computer, including proficiency in Word, Access, Excel, Outlook, and clinical databases, using talk-and-type documentation.

Responsibilities

Represent the Plan by providing complex clinical support for corporate, departmental, and special projects relating to Complaints, Grievances, and Appeals.
Draft recommendations concerning matters affecting Complaints, Grievances, and Appeals, and communicate and help resolve issues.
Identify, review, and analyze complex clinical issues involving corporate policies and procedures, including issues raised internally or through complaints, grievances, and appeals.
Contact Management, Government Programs, and external contacts such as group leaders to discuss questions and issues.
Recommend improvements, updates, or clarifications to policies and procedures.
Follow up on policy and procedure changes to ensure implementation and request or initiate revisions to supporting documentation.
Serve as department liaison on cases and issues requiring legal recommendations and direction.
Provide Plan personnel with clinical guidance on inquiry resolution in accordance with CMS, NCQA, provider contracts, and established Member Touchpoint 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.
Provide functional training for peers as workload requires.
Provide rotating on-call coverage on weekends and holidays.