Blue Cross of Idaho is seeking a Clinical Appeals nurse who can handle the clinical review of provider and member appeals for all product lines. This individual will ensure timely resolution within required turnaround times, utilizing member contract or EOC, published clinical criteria, medical policy or Medicare coverage criteria, as applicable.
Hybrid and remote work is supported. #LI-Hybrid
We’re looking for a Clinical Appeals Nurse with:
Experience: 3 years’ clinical nursing to include health insurance experience
Education: Associate Degree in Nursing or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)
Licenses/Certifications: Valid unrestricted Registered Nursing License (in State of Residence)
What a day of a Clinical Appeals Nurse would look like:
- Manage clinical appeal inventory of assigned product lines to achieve required turnaround time.
- Document clinical review process in the appropriate system and follow-ups with authorization entry, when applicable.
- Review correspondence and medical records.
- Makes clinical decisions using approved and accepted plan policies and criteria.
- Provide comprehensive reviews and referrals to physician review.
- Identify and refer cases to the Special Investigation Unit.
- Actively participate in interdepartmental process improvement activities.
- Document and report potential quality of care or service issues to leadership.
- Attend, participate, and share information with team from assigned committees.
- Perform other duties and responsibilities as assigned.
Additional skills that we are looking for:
- Clinical criteria and medical policy
- Claim review processes
- Utilization Management Processes
- Quality Improvement
- Medicare guidance and requirements
- Interqual
- Use of Electronic Medical Records
- Analytical and critical thinking
- Interpersonal, verbal, and written communication
- Self-motivation
- Collaboration
As of the date of this posting, a good faith estimate of the current pay range is $73,321 to $102,650. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).
The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.
We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.
We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.
Reasonable accommodations
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.