Clinical Appeals Nurse
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: 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)
Requirements
- 3 years’ clinical nursing to include health insurance experience
- Associate Degree in Nursing or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)
- Valid unrestricted Registered Nursing License (in State of Residence)
- 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.
Benefits
- 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
- paid family leave program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
