Job Responsibilities
- Initiate referrals to ensure appropriate coordination of care.
- Seek the advice of the Medical Director when appropriate, according to policy.
- Assists non-clinical staff in performance of administrative reviews
- Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
- Occasional weekend work may be required.
- Must be able to pass Windows navigation test.
- Testing/Assessments will be required for Digital positions.
- Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.
Job Qualifications
License
- Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Experience
- 3 years - Clinical experience required
Skills\\Certifications
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Working knowledge of URAC, NCQA and CMS accreditations
- Must be able to work in an independent and creative manner.
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Ability to manage multiple projects and priorities
- Adaptive to high pace and changing environment
- Customer service oriented
- Superior interpersonal, client relations and problem-solving skills
- Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
