Remote Clinical Appeals Nurse | Medical Appeals Expert

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 67,320 - 133,705; Full time

Job summary

CareFirst BlueCross BlueShield in the Baltimore area is seeking an experienced Clinical Appeals Nurse to evaluate member and provider disputes related to adverse coverage decisions. The role is remote from within the greater Baltimore area with periodic on-site attendance for meetings and training.

You will apply nursing expertise, regulatory knowledge, and collaboration with physicians and review organizations to determine appropriate decisions and communicate outcomes to members and providers.

Qualifications

• Bachelor's degree in nursing or equivalent 4 years of relevant work experience.
• 3 years of clinically related experience in Medical Review, Utilization Management, or RN direct patient care or health insurance payor experience.
• RN – Registered Nurse – State Licensure required upon hire.

Responsibilities

• Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources.
• Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information and prepares the written case.
• Collaborates with Independent Review Organizations and contracted panel physicians to obtain clinical opinions.
• Maintains a current knowledge base of medical practices and regulatory requirements.

Skills

Medical terminology

Regulatory requirements

Communication

Analytical skills

Microsoft Office

Prioritization and multitasking

Education

Bachelor's degree in Nursing

BSN/MSN Degree

Job description

CareFirst BlueCross BlueShield in the Baltimore area is seeking an experienced Clinical Appeals Nurse to evaluate member and provider disputes related to adverse coverage decisions. The role is remote from within the greater Baltimore area with periodic on-site attendance for meetings and training.

You will apply nursing expertise, regulatory knowledge, and collaboration with physicians and review organizations to determine appropriate decisions and communicate outcomes to members and providers.