Medicare Appeals RN

GuideWell • Jacksonville, FL

2d • Onsite

About The Position

The Appeals & Post Service Review RN role is centered on the daily case review for appeals from members, members' beneficiary representatives, and providers in order to meet timeliness & documentation compliance metrics. In addition, the role also is responsible for post service review and clinical provider appeals. Facilitates final determination based on findings and procedures within strict timelines established by regulatory requirements. Authors final appropriate statement supporting final determination based on appropriate criteria or medical director determination.

Requirements

• 2+ years of clinical experience in a related field
• Bachelor's degree in a related field or equivalent work experience
• Current State of Florida Licensed Registered Nurse (RN) with unrestricted licensure or Compact State Licensure
• Proven experience with Medical Coverage Guidelines, including medical necessity and experimental/investigational procedures
• Excellent communication skills for interacting with internal and external customers
• Ability to multitask and navigate multiple research and processing systems simultaneously
• Familiarity with HIPAA and ERISA requirements
• Knowledge of regulatory requirements
• Ability to work under tight deadlines
• Proficiency in Microsoft Office (Word, PowerPoint, Excel)

Nice To Haves

• Experience with BCBSF systems, including: Legacy Diamond Siebel PIP TSO CMCA FAM Convergence Network Contracting Medical Coverage Guidelines
• Knowledge of BCBSFL policies and procedures

Responsibilities

• Reviews and researches appeals to reach timely, appropriate determination.
• Reviews and researches member and provider appeals and their medical documentation, abstracts pertinent data into the documentation system, and reviews with Medical Director to reach a final determination.
• Processes Post Service reviews, abstracts pertinent data into the documentation system, reviews with Medical Director, as appropriate, to reach determination.
• Accesses Legacy or Diamond to review how claim was originally processed as needed.
• Interpret BCBSF Medical Coverage Guidelines for staff.
• Responsible for research, preparation, and presentation of clinical appeal cases (medical necessity and experimental/investigational procedures).
• Works with business partners across the organization, as needed, to gather data as input for final determination.
• Prepares Independent Review Entity (Maximus) packages and assists team members with case review to ensure all documentation is included in the package.
• Follows regulatory requirements as appropriate and corporate values, policies and procedures.
• Ensures final determination is reached and communicated within strict timelines.

Benefits

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available
• A comprehensive wellness program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level