Med Review and Appeals RN - Medical Review and Appeals

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: position summary,analysis,benefits,teamwork,nurse,performance,communication,knowledge,skills,degree,certificates, licenses, and registrations,experience,departmental preferences

Full-Time

Competitive Total Compensation Package

Overview: Description for Internal Candidates Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, , including appeal requests initiated by providers, facilities and members. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
Responsibilities: <ul> <li>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.&nbsp;</li> <li>Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.</li> <li>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.</li> <li>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.</li> <li>Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.</li> <li>Other duties may be assigned based on designated department assignment.</li> </ul> <p><strong><u>VENDOR PROGRAMS</u></strong></p> <ul> <li>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.&nbsp;</li> <li>Educate member services and members/providers on member benefits.&nbsp;</li> <li>Assist with answering questions, supplying information and training on UM program (internally and externally).</li> <li>Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations.&nbsp;</li> <li>Evaluate clinical documentation to resolve member inquires as to UM decisions and appeals/grievances.&nbsp;</li> <li>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.</li> <li>Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services.&nbsp;</li> <li>Work with cross functional teams to resolve issues/concerns/inquiries.</li> <li>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.&nbsp;</li> <li>Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities.</li> </ul>
Requirements: <ul> <li>Bachelor's degree in nursing, allied health, business, or related field preferred.</li> <li>Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.</li> <li>Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.</li> <li>One (1) year health insurance plan experience or managed care environment preferred.</li> <li>Registered Nurse with current unrestricted Michigan Registered Nurse license required.</li> <li>Certification in Case Management may be preferred based upon designated department assignment.</li> <li>Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.</li> <li>Working knowledge of current industry Microsoft Office Suite PC applications.</li> <li>Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.</li> <li>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.</li> <li>Knowledge of cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources.</li> <li>Knowledge of applicable accreditation standards, local, state and federal regulations.</li> <li>Other related skills and/or abilities may be required to perform this job based upon designated department assignment.</li> </ul> <br /> <p><strong>Departmental Preferences:</strong></p> <ul> <li>Ability to read claim utilization</li> <li>Ability to read a medical policy and apply criteria to medical records</li> <li>Ability to manage more than one task at a time</li> <li>Excellent verbal and written communication skills</li> <li>Knowledge of CPT and ICD-10 codes</li> <li>Knowledge of the difference between a Self-Funded group and Underwritten group</li> <li>Knowledge of NCQA standards</li> <li>1-3 years Blue Cross Blue Shield of Michigan experience</li> </ul>