Clinical Appeals Nurse (Remote)

Resp & Qualifications PURPOSE: This position will support the government programs line of business. The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage reputed company. The Clinical Appeals Nurse utilizes clinical skills and knowledge of reputed company applicable State and Federal rules and regulations that govern the appeal process for reputed company and Government Programs lines of business in order to formulate a professional response to the appeal request. We are looking for an reputed company professional to work remotely from reputed company the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business reputed company activities. ESSENTIAL FUNCTIONS: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal reputed company holders and any other initiators. Responds to such requests with original letters, reputed company and technical in nature, upholding corporate policies and reputed company while meeting reputed company State and Federal regulations and mandates. Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and reputed company External appeal rights. Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and reputed company available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse reputed company are appropriate. Interpret and apply, as appropriate Regulatory and accreditation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse reputed company are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS. Maintains a reputed company command of a continuously expanding knowledge reputed company of reputed company medical practices and procedures, including reputed company medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications. QUALIFICATIONS: Education Level : High School Diploma or GED 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 reputed company, or similar Managed Care organization or hospital preferred. BSN/MSN Degree 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 reputed company 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. 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 Salary Range: $66,960 - $132,990 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation reputed company depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (reputed company benefits/incentives are subject to eligibility requirements). Department MA and EGWP Appeals and Grievances Equal Employment Opportunity reputed company is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to reputed company reputed company applicants without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, protected veteran or disabled status, or genetic information. Where To Apply Please to apply: Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to reputed company work directly or indirectly on Federal health care programs. PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. Sponsorship in US Must be eligible to work in the U.S. without Sponsorship. #LI-SS1 Apply tot his job Apply To this Job