RN Appeals Coordinator

Arkansas Blue Cross and Blue Shield; Little Rock (AR); Remote; USD 70,000 - 95,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield seeks an Appeals Coordinator with a strong nursing background to review adverse benefit determinations within regulatory timeframes. You will apply medical guidelines and corporate policies, drawing on HCPCS/CPT knowledge and claims rules, to facilitate timely reimbursements.

The role requires RN licensure, 5 years of clinical nursing, and 2 years in utilization review or case management. Collaboration and independent judgment are key to success.

Qualifications

• Bachelor's degree in Nursing preferred and RN license in good standing.
• Minimum five years of clinical nursing experience with broad background.
• Knowledge of HCPCS/CPT/Revenue codes and general coding principles.
• Knowledge of claims processing rules, health plan operations and regulations.
• At least two years in utilization review, medical policy or case management; appeals experience preferred.

Responsibilities

• Appeals: Researches appeal cases for diagnosis codes and medical necessity; provides comprehensive responses according to standards and policy.
• Communication: Collaborates with medical divisions on legal issues related to benefits and explains policy application.
• Compliance: Practices nursing within licensure; adheres to URAC standards and state regulations; uses facts to ensure care and safety.
• Knowledge: Stays current with medical procedures, products, and enterprise policies and contracts.
• Other duties as assigned.

Skills

Analytical Decision Making

Decision Making

Critical Thinking

Time Management

Interpersonal Relationships

Needs Assessment

Researching

Sound Judgment

Education

Bachelor's degree in Nursing

RN License

Tools

Microsoft Excel

Microsoft Office

PowerPoint

Word

Outlook

Job description

Job SummaryThe Appeals Coordinator is accountable for reviewing appeals pursuant to an adverse benefit determination within the timeframes set forth in both federal and state law by applying corporate and medical guidelines and policies. This position requires extensive knowledge of Federal, State, payer regulations, and reimbursement methodologies to facilitate timely and accurate reimbursement. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether or not an adverse benefit determination was legal, appropriate, impartial and fair. This position reports to Senior Counsel.RequirementsEDUCATIONBachelor's degree in Nursing preferred.LICENSING/CERTIFICATIONRegistered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.EXPERIENCEMinimum five (5) years' clinical nursing experience, to include a broad background in various facets of nursing.Knowledge of HCPCS/CPT/Revenue codes and general coding principles.Knowledge of claims processing rules/logic.Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.Minimum two (2) years' in utilization review, medical policy, and/or case management experience required. Previous experience in appeals and/or grievances process preferred.ESSENTIAL SKILLS & ABILITIESExcellent oral & written communication skillsDetail-OrientedStrong analytical, critical thinking, organizational and time management skillsProficiency using basic computer skills in Microsoft Office such as Word, Excel, Outlook, and PowerPoint, including the ability to navigate multiple systems and keyboarding.Ability to make sound judgments and decisions based on facts and guidelines.Ability to build collaborative relationships.Ability to work independently with little supervision.Ability to interpret complex documentation.Skills• Analytical Decision Making• Business Compliance• Collaborative Communications• Critical Thinking• Cross-Functional Communications• Data Analysis• Document Recording• Information Interpretation• Interpersonal Relationship Management• Law• Microsoft Excel• Microsoft Office• Needs Assessment• Researching• Sound Judgment• Time ManagementResponsibilities• Appeals: Researches appeal cases for diagnosis codes and medical necessity; provides comprehensive responses, according to accepted standards of medical practice and corporate medical policy, code review logic, contractual guidelines and regulatory requirements.• Communication: Collaborates with various medical divisions concerning legal issues related to benefits and must be able to understand and explain medical coverage policy application. Respond to the Arkansas Insurance Department and any other state insurance department who has received a complaint and to any appeal of an adverse benefit determination made by a member, provider, attorney or personal representative of a member of Arkansas Blue Cross within the timeframe allowed by state and federal law.• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.• Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.• Other duties as assigned.CertificationsRegistered Nurse (RN) - Arkansas State Board of NursingSecurity RequirementsThis position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.Segregation of DutiesSegregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.Employment TypeRegularADA Requirements2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.