RN Med Review and Appeals-Commercial Inpatient Precert-Detroit, Tower

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.<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 />Learn more about your options as an external candidate. <a href="https://bcbsm.taleo.net/careersection/2/jobsearch.ftl?lang=en" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: performance,analysis,communication,medical,consulting,nurse,reporting,knowledge,medical,performance,degree,experience,certification


Competitive Compensation and Benefits 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><span style="font-size: small;">Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.</span></li> <li><span style="font-size: small;">Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.</span></li> <li><span style="font-size: small;">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;</span></li> <li><span style="font-size: small;">Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.</span></li> <li><span style="font-size: small;">Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.</span></li> <li><span style="font-size: small;">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.</span></li> <li><span style="font-size: small;">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.</span></li> <li><span style="font-size: small;">Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.</span></li> <li><span style="font-size: small;">As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.</span></li> <li><span style="font-size: small;">Other duties may be assigned based on designated department assignment.</span></li> </ul> <span style="font-size: small;"><u><strong>VENDOR PROGRAMS</strong></u></span> <div> <ul> <li><span style="font-size: small;">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;</span></li> <li><span style="font-size: small;">Educate member services and members/providers on member benefits.&nbsp;</span></li> <li><span style="font-size: small;">Assist with answering questions, supplying information and training on UM program (internally and externally).</span></li> <li><span style="font-size: small;">Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations.&nbsp;</span></li> <li><span style="font-size: small;">Evaluate clinical documentation to resolve member inquires as to UM decisions and appeals/grievances.&nbsp;</span></li> <li><span style="font-size: small;">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.</span></li> <li><span style="font-size: small;">Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services.&nbsp;</span></li> <li><span style="font-size: small;">Work with cross functional teams to resolve issues/concerns/inquiries.</span></li> <li><span style="font-size: small;">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;</span></li> <li><span style="font-size: small;">Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities.</span></li> </ul> </div>
Requirements: <ul> <li><span style="font-family: Arial; font-size: small;">Bachelor's degree in nursing, allied health, business, or related field preferred.</span></li> <li><span style="font-family: Arial; font-size: small;">Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.</span></li> <li><span style="font-family: Arial; font-size: small;">Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.</span></li> <li><span style="font-family: Arial; font-size: small;">One (1) year health insurance plan experience or managed care environment preferred.</span></li> <li><span style="font-family: Arial; font-size: small;">Registered Nurse with current unrestricted Michigan Registered Nurse license required.</span></li> <li><span style="font-family: Arial; font-size: small;">Certification in Case Management may be preferred based upon designated department assignment.</span></li> <li><span style="font-family: Arial; font-size: small;">Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.</span></li> <li><span style="font-family: Arial; font-size: small;">Working knowledge of current industry Microsoft Office Suite PC applications.</span></li> <li><span style="font-family: Arial; font-size: small;">Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.</span></li> <li><span style="font-family: Arial; font-size: small;">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.</span></li> <li><span style="font-family: Arial; font-size: small;">Knowledge of cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources.</span></li> <li><span style="font-family: Arial; font-size: small;">Knowledge of applicable accreditation standards, local, state and federal regulations.</span></li> <li><span style="font-family: Arial; font-size: small;">Other related skills and/or abilities may be required to perform this job based upon designated department assignment.</span></li> </ul>