Med Review and Appeals RN - UM Program Mgmt

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.

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="" 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="" 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="" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions.

keywords: performance,establish,analysis,medical,consulting,develop,establish,research,knowledge,experience,teamwork,communication,degree,quality assurance


Competitive Total Compensation Package

Overview: Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments
Responsibilities: <ul> <li>Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.</li> <li>Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.</li> <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>Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.</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>As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.</li> <li>Other duties may be assigned based on designated department assignment.</li> </ul>
Requirements: <strong>Qualifications</strong> <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> <p><strong>Department Summary / Preferences:</strong></p> <p>Primary focus includes outreaching to members with prior authorization denials to ensure understanding of denial and identify next steps and needs unique to the member</p> <ul> <li>Background in assisting patients to meet their healthcare needs.</li> <li>Primary focus includes outreaching to members with prior authorization denials to ensure understanding of denial and identify next steps and needs unique to the member</li> <li>Uses familiarity with UM Processes to solution member issues</li> <li>Collaborates with stakeholders to resolve member needs</li> <li>Utilizes Care Advance to create unique case logs for all member outreaches</li> <li>Utilizes clinical knowledge to assess denial rationale and appropriate next steps for members with prior authorization denials</li> <li>Responsible for verifying and complying with all HIPPA standards</li> <li>Responsible for understanding of multiple vendor programs to successfully support member interactions</li> <li>Responsible for documenting in the case record and summarizing key cases for leadership review</li> <li>Works independently to achieve call goals.&nbsp;</li> <li>Collaborates with vendor contacts to mitigate member issues identified during outreach</li> <li>Utilizes scripting and communication skills to facilitate positive member interactions.&nbsp;</li> </ul>