Analysis Skills, Biotech and Pharmaceutical, Claims Processing, Clinical Assessment, Clinical Medicine, Compensation and Benefits, Contract Review, Corporate Policies, Corrective Action, Documentation, Employee Benefits, Federal Government, Leadership, Licensed Practical Nurse/Licensed Vocational Nurse, Maintain Compliance, National Committee for Quality Assurance (NCQA), Occupational Therapy, Operating Room Nursing, Physical Therapy, Registered Nurse (RN), Resolve Customer Issues, Risk, Staff Training, Time Management, Trend Analysis
Screening Question:
Tell us about your exp with clinical coverage criteriaRegistered Nurse in the state of North Carolina
3 years of clinical experence; OR Licensed Practical Nurse, Physical Therapist, Occupational Therapist,
Licensed in the State of North Carolina and 5 years of clinical experience.
Description:- Provide clinical consultation with non-clinical staff within the Appeals Department.
- Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.
- Assist with Level 3 appeals as required.
- Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.
- Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.
- Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.
- Initiate claim adjustments on individual cases when necessary.
- Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.
- Identify trends and high-risk issues to make recommendations to address future exposure.
- Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.
- Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.
- Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
- May handle complaints/grievances as defined by the federal government.
- Coordinates with external vendors and provides requested information as requested.
Hiring Requirements
Registered Nurse in the state of North Carolina
3 years of clinical experence; OR Licensed Practical Nurse, Physical Therapist, Occupational Therapist,
Licensed in the State of North Carolina and 5 years of clinical experience.
EEO:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.