RN Appeals Coordinator - Remote Health Policy Expert

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

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.