Clinical Case Specialist (RN)

BCBS of Rhode Island is currently interviewing Clinical Case Specialist (RN) on Wed, 04 Sep 2013 10:10:37 GMT. At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation...
Clinical Case Specialist (RN)

Location: Providence Rhode Island

Description: BCBS of Rhode Island is currently interviewing Clinical Case Specialist (RN) right now, this vacancy will be placed in Rhode Island. Further informations about this vacancy opportunity kindly read the description below. At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of tod! ay's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, gender identity or expression.
JOB SUMMARY
Investigate and resolve medical necessity appeals on all company products. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services, US Department of Labor, RI Department of Health, and the Affordable Care Act as well as NCQA accreditation requirements. Maintain all appeals documentation according to internal procedures and external agency requirements.
ESSENTIAL JOB FUNCTIONS
Investigate and resolve medical necessity appeals for all company products, including appeals for delegated functions such as but not limited to behavioral health, pharmacy, and high-end radiology. Maintain documentation of cases.
Gather all pertinent clinica! l data to ensure a full and comprehensive review and a fair de! cision consistent with our medical policies and our members' benefits.
Ensure weekend coverage for fast track appeals resulting from discharges from Skilled Nursing Facilities, in accordance with federal regulations. Ensure all forms, particularly the Detailed Notice of Non-Coverage are appropriately completed and delivered timely, also in accordance with federal regulations.
Prepare cases, including summarization of all pertinent data, for medical director review. Ensure medical directors are aware of any clinical information that may affect the outcome of the case, as well as internal medical policy supporting documentation, BCBSA medical policy, and local and national coverage determinations that are pertinent to the decision at hand.
Ensure expedited cases are handled timely and in accordance with all internal procedures and state and/or federal requirements.
Respond to internal and external inquiries, assist with special member cases, and suggest resolu! tions via telephone or written communication.
Identify potential quality of care issues within medical appeals; escalate as appropriate.
Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary.
Participate in departmental audits in preparation of regulatory site visits.
Serve as a resource for less experienced or non-clinical members of the department.
Participate in department initiatives and projects.
Perform other duties as assigned.

QUALIFICATIONS:Minimum Education and Experience: Bachelor's degree in Nursing, Business Management, or related field, or an equivalent combination of education and experience Valid Rhode Island Registered Nurse license Three to five years acute care clinical experience Preferred Education, Additional Qualifications and Experience: Experience in a ! managed care environment

Required Knowledge, Skills, and/or! Abilities:Knowledge of health insurance laws and regulationsKnowledge of utilization management appeals processesAdvanced analytical skills, with the ability to interpret and synthesize complex data setsGood business acumen and political savvyKnowledge of business process improvement techniques and strategiesExcellent verbal and written communications skillsNegotiation skillsPresentation skillsDecision-making skillsGood problem solving skillsAbility to interface with employees at all levelsAbility to effectively navigate ambiguous situations with limited directionExcellent organizational skills and ability to successfully prioritize multiple tasksAbility to handle multiple priorities/projects
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to BCBS of Rhode Island.

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This vacancy starts available on: Wed, 04 Sep 2013 10:10:37 GMT

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