Resp & QualificationsPURPOSE:The Sr Clinical Medical Review Nurse handles day to day review of complex professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and/or adjudication. The position handles difficult cases which cannot be completed by the entry level Clinical Medical Review Nurse. The incumbent will handle pre and post claim medical review for Commercial and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions.ESSENTIAL FUNCTIONS:
Receives, researches, reviews and analyzes complex professional and institutional claims using critical thinking, nursing clinical judgment and corporate/medical policies for claims processing and/or adjudication, performs high-level research on topics identified as actual or potential medical policies. Assesses, communicates and elevates issues that may require assessment by medical policy.
Provides pricing of procedure codes which require individual consideration or are listed as not otherwise classified in CPT manual. Interprets the descriptive or medical information utilizing the CPT and HCPCS manuals. Keeps up to date on coding rules and standards.
Participates in medical policy meetings, nurse's forums, and review sessions with Medical and Dental directors, special projects, task forces, committees as assigned.
Acts as mentor to new associates or existing associates being cross trained on different functions
Performs medical underwriting by reviewing applications of potential subscribers, as well as any appropriate medical records.
SUPERVISORY RESPONSIBILITY:Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.QUALIFICATIONS:Education Level: High School Diploma or GED.Licenses/Certifications:
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required.
Experience: 5 years acute clinical experience, previous case management, discharge planning or utilization review experience.Preferred Qualifications:
Bachelor's degree.
Knowledge, Skills and Abilities (KSAs)
Ability to effectively communicate and provide positive customer service to every internal and external customer.
Must possess excellent written and verbal communication.
Strong organizational skills, ability to prioritize responsibilities with attention to detail.
Ability to produce accurate and comprehensive work timely with minimal direction.
Strong interpersonal skills. Ability to work independently, as well as a member of a team.
Self-motivated, able to take initiative, and work independently with minimal oversight to meet timeliness, strong follow-through skills and a solutions-oriented attitude., Advanced
Current knowledge of clinical practices and related medical policies.
Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technology.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $71,496 - $141,999Salary Range DisclaimerThe disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).DepartmentMD RN ReviewEqual Employment OpportunityCareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.Where To ApplyPlease visit our website to apply: www.carefirst.com/careersFederal Disc/Physical DemandNote: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.Sponsorship in USMust be eligible to work in the U.S. without Sponsorship#LI-SS1REQNUMBER: 19769