Appeals and Clinical Research RN

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.

This position is eligible for 100% remote work, but must be able to also work in the Fargo, ND office as requested by leadership. 

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 appeals/clinical research, health insurance utilization/medical review or related experience is required.

 

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

 

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

 

Physical Demands

Standing

Occasional (30-60%)

Walking

Occasional (30-60%)

Use of Computer

Frequent (60-90%)

Sitting

Frequent (60-90%)

Talking

Frequent (60-90%)

Hearing

Frequent (60-90%)

 

Other Information

Important Notice: BCBSND has a vaccination protocol in place that requires any employees who physically work in a BCBSND office or whose role requires direct customer contact to be vaccinated against COVID-19. We respect your choice to get vaccinated (or not) and getting vaccinated is not a condition of employment. If you are not vaccinated, you may work remotely if your role allows for it. If your role does not allow for remote work and you are unable to get the COVID-19 vaccine, there is an exception process available that includes a weekly testing regimen.

 

Job Posting Policy

Employees new to Blue Cross Blue Shield of North Dakota are eligible to apply for positions within their assigned department after successfully completing 90-days in their role. For positions outside of their department, new employees should attain a minimum of six months of service before applying for a new role. Exceptions to this are acceptable, provided there is good business justification for making the move.

 

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 10/29/2021 at 8:00AM CST. No further applications will be considered.