Clinical Appeals Nurse

Blue Cross of Idaho•Bozeman, MT

15d•$73,321 - $102,650•Hybrid

About The Position

Blue Cross of Idaho is seeking a Clinical Appeals nurse who can handle the clinical review of provider and member appeals for all product lines. This individual will ensure timely resolution within required turnaround times, utilizing member contract or EOC, published clinical criteria, medical policy or Medicare coverage criteria, as applicable. Hybrid and remote work is supported. #LI-Hybrid We're looking for a Clinical Appeals Nurse with: As of the date of this posting, a good faith estimate of the current pay range is $73,321 to $102,650. The position is eligible for an annual incentive bonus (variable depending on company and employee performance). The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer. We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program. We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies. Reasonable accommodations To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Blue Cross of Idaho has taken our role as an Idaho-based health insurance company to heart since 1945. As a not-for-profit, we are driven to help connect Idahoans to quality and affordable healthcare while building strong networks and services. We aim to create a brighter future for all with the help of customer-centric professionals. Your Health and Wellness Matters At Blue Cross of Idaho, we care about the health and well-being of our employees. Our benefits aim to help make your life easier, healthier and more balanced. Your Career Development Matters We believe in employee growth, which is why we offer training, tools and numerous resources to assist with professional development. Your Community Matters Our employees care deeply about Idaho. We work together to positively impact communities throughout Idaho, and contribute our time through volunteering. Blue Cross of Idaho will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully use electronic and online job application systems. For assistance, please send an email to [email protected]. Equal Opportunity is the Law EEO is the Law Supplement E-Verify Pay Transparency

Requirements

Experience: 3 years’ clinical nursing to include health insurance experience
Education: Associate Degree in Nursing or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)
Licenses/Certifications: Valid unrestricted Registered Nursing License (in State of Residence)

Nice To Haves

Clinical criteria and medical policy
Claim review processes
Utilization Management Processes
Quality Improvement
Medicare guidance and requirements
Interqual
Use of Electronic Medical Records
Analytical and critical thinking
Interpersonal, verbal, and written communication
Self-motivation
Collaboration

Responsibilities

Manage clinical appeal inventory of assigned product lines to achieve required turnaround time.
Document clinical review process in the appropriate system and follow-ups with authorization entry, when applicable.
Review correspondence and medical records.
Makes clinical decisions using approved and accepted plan policies and criteria.
Provide comprehensive reviews and referrals to physician review.
Identify and refer cases to the Special Investigation Unit.
Actively participate in interdepartmental process improvement activities.
Document and report potential quality of care or service issues to leadership.
Attend, participate, and share information with team from assigned committees.
Perform other duties and responsibilities as assigned.