Clinical Appeals Nurse (Remote) ID-1751

PURPOSE:
The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Government Programs lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

ESSENTIAL FUNCTIONS:

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Licenses/Certifications:

  • RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
  • CCM - Certified Case Manager Upon Hire Preferred
  • LNCC - Legal Nurse Consultant Certified Upon Hire Preferred


Experience: 2 years medical-surgical or similar clinical experience OR 3 years' experience in mental health, psychiatric setting.

Preferred Qualifications:

  • 2 years' experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred.
  • BSN/MSN Degree. Government Program experience with Appeals and Grievance, Experience with MCG, InterQual, NCD and LCD's.

Knowledge, Skills and Abilities (KSAs)

  • Knowledge and understanding of medical terminology.
  • Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
  • Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task.
  • Ability to effectively communicate and provide positive customer service to every internal and external customer.
  • Knowledge of Microsoft Office programs.
  • Excellent analytical and problem-solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case-by-case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions.
  • Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
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