Med Review and Appeals RN - Clinical Review at Blue Cross… · Detroit

Med Review and Appeals RN - Clinical Review

Location: Detroit, MI, United States

• 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.
• Other duties may be assigned based on designated department assignment.

VENDOR PROGRAMS

• Responsible for responding 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 inquires 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. 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.

"Qualifications"

• Bachelor's degree in nursing, allied health, business, or related field preferred.
• 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.
• One (1) year health insurance plan experience or managed care environment preferred.
• Registered Nurse with current unrestricted Michigan Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment.
• 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.
• Other related skills and/or abilities may be required to perform this job based upon designated department assignment.

Departmental Preferences

• 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.