Med Review and Appeals RN - Clinical Review

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

This role involves performing prospective, concurrent, and retrospective reviews of various healthcare services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care. This includes handling appeal requests from providers, facilities, and members. The position may also involve establishing care plans and coordinating care through the healthcare continuum, including member outreach assessments. A key aspect is reviewing, researching, and authorizing requests for services, and contacting medical personnel to recommend alternative treatments or service levels using approved clinical protocols. The role requires analyzing and preparing documentation for retrospective reviews and appeals in accordance with regulatory and accreditation standards. Establishing and communicating discharge planning needs, analyzing patterns of care, resolving issues related to benefits and eligibility, and identifying quality of care issues are also core responsibilities. Additionally, the role involves developing and delivering targeted education to the provider community and potentially negotiating reimbursement rates for non-contracted providers. Under the Vendor Programs section, responsibilities include responding to member inquiries, communicating clinical information related to vendor decisions, educating members and providers on benefits, and assisting with training on Utilization Management (UM) programs. The role also requires assessing member health needs, evaluating clinical documentation for UM decisions and appeals, reviewing claims issues related to UM programs, and utilizing approved resources to provide members with appropriate services. Collaboration with cross-functional teams and compiling/reporting data are also part of this function.

Requirements

Registered Nurse with current unrestricted Michigan Registered Nurse license, Licensed Physical Therapist or Licensed Occupational Therapist required.
Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities.
Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
Registered Nurse with current unrestricted Michigan Registered Nurse license required.
Excellent written and verbal communication skills.
Excellent customer service and interpersonal skills.
Working knowledge of current industry Microsoft Office Suite PC applications.
Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service.
Knowledge of cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources.
Knowledge of applicable accreditation standards, local, state and federal regulations.

Nice To Haves

Bachelor's degree in nursing, allied health, business, or related field preferred.
One (1) year health insurance plan experience or managed care environment preferred.
Certification in Case Management may be preferred based upon designated department assignment.
Post-acute care specific experience, including experience with skilled nursing, inpatient rehabilitation, or long-term acute care settings.
Experience applying InterQual criteria or similar nationally recognized clinical criteria to support medical necessity and level-of-care determinations.
Experience in care coordination, including collaboration with internal and external stakeholders to support appropriate transitions of care.
Excellent typing skills with the ability to accurately and efficiently document clinical information.

Responsibilities

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.
Establish care plans and coordinate care through the health care continuum including member outreach assessments.
Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
Identify and document quality of care issues; resolve or route appropriate area for resolution.
Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
Respond to BCBSM member level inquiries received from customer service, communicating the clinical information related to decisions our vendors make on our behalf for medical necessity.
Educate member services and members/providers on member benefits.
Assist with answering questions, supplying information and training on UM program (internally and externally).
Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations.
Evaluate clinical documentation to resolve member inquiries as to UM decisions and appeals/grievances.
Review claims issues pertaining to UM program to ensure correct reimbursement for covered/and or approved services, and resolve, and/or devise solutions to mitigate any gaps identified.
Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services.
Work with cross functional teams to resolve issues/concerns/inquiries.
Compile and report data based on member and provider inquiries.