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Appeals and Clinical Research RN

Employer
Blue Cross Blue Shield of ND
Location
Fargo, North Dakota
Salary
Join our team!

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Job Details

Job Summary

The Appeals and Clinical Research RN is responsible for determining medical necessity on appeal requests in a timely and accurate manner. This role has oversight of the appeals policies and procedures for Blue Cross Blue Shield North Dakota (BCBSND) and ensures procedures are in compliance with state and federal regulations along with all other quality standards, accreditations and certifications. The Appeals and Clinical Research RN is also responsible for providing research, support and recommendations for medical policy development. Through the review and appeals determination process, this role also provides education to appropriate parties regarding proper appeal processes to ensure accuracy and consistency of processes and procedures throughout the company.

Essential Functions
  • Reviews and makes appropriate appeal determinations according to applicable appeal policies and procedures and medical policy. Handles emergent and standard appeal requests and makes appropriate determinations using medical knowledge, judgement, expertise, and interpretation of medical policy and standards of practice. Prepares cases for review by the Medical Director so a final determination can be made.
  • Prepares and analyzes appeals reports to provide guidance in the management and improvement of the Utilization review effort.
  • Assists with reviews of existing medical policies and development of new policies in collaboration with Medical Directors and Medical Policy Leadership. Identifies trends that may need to be addressed in policy and works collaboratively with leadership to incorporate them as appropriate. Assists with appropriate research needed including regulatory standards, standards of practice, utilization studies, plan surveys, literature research and consultants.
  • Serves as a clinical point of contact for the organization for numerous internal parties and provides education on appeals processes to areas of the organization as appropriate.
  • Researches complex clinical issues and internal resources including benefit matrix, benefit plans, polices and external sources which may impact claims.
  • Prioritizes workload to ensure timeliness standards are met

Knowledge, Skills, and Abilities

Nursing Expertise

Advanced

Communication (Verbal/Written)

Intermediate

Decision Making

Intermediate

Analytical Thinking

Intermediate

Research and Data Analysis

Intermediate

Prioritization and Organization of Work

Intermediate

 

Education Requirements

Required: Associate's                                         Preferred: Bachelor's

Field(s) of Study: Completion of RN program is required; BSN is highly preferred

 

Experience Requirements

Required: Minimum of 3 Years                       Preferred: Minimum of 5 Years

Experience Details:

Minimum of 3 years of clinical/patient care or related experience is required; variety of clinical, hospital, skilled nursing experience is highly desirable; candidate must possess in-depth medical knowledge, critical thinking skills and expertise in interpretation and application of medical policy/criteria, utilization management processes, medical criteria/guidelines, contract benefits and the ability to research medical diagnoses, procedures and technology.

 

Certification, Licensures & Registration Requirements

Title: North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND             State or Agency: Board of Nursing

Preference for RN with coding certification, including CPC, CPC-H, RHIT, CCSP or related.

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

 

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

 

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com

This job posting will be closed 02/12/2021 at 8:00AM CST. No further applications will be considered.

Company

TWO WORDS – MEMBERS FIRST.

That sums up why we’re here. And according to member satisfaction surveys, 95.6% say we’ve done a great job at maintaining that focus.

With that said, there are still mountains to move. America’s health care system needs an overhaul and Blue Cross Blue Shield of North Dakota is taking a lead role. To accomplish that, we need BOLD people who believe they can make an impact.

Are you ready to shake up an industry?

If you’re passionate about taking on our nation’s number one health care concern, there may be a place for you on one of our teams.

Company info
Website
Location
4510 13th Ave. S.
Fargo
ND
58103
United States

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