Clinical Case Specialist (RN)

BCBS of Rhode reputed company is currently interviewing Clinical Case Specialist (RN) on Wed, 04 Sep 2013 10:10:37 GMT. At reputed company (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national reputed company, disability, veteran status, sexual orientation... Clinical Case Specialist (RN) Location: reputed company Rhode reputed company Description: BCBS of Rhode reputed company is currently interviewing Clinical Case Specialist (RN) right now, this vacancy will be reputed company in Rhode reputed company. Further informations about this vacancy opportunity kindly read the description below. At reputed company (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of tod! ay's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national reputed company, disability, veteran status, sexual orientation, gender identity or expression. JOB SUMMARY Investigate and resolve medical necessity appeals on reputed company company products. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services, US reputed company, RI Department of Health, and the reputed company Act as well as NCQA accreditation requirements. Maintain reputed company appeals documentation according to internal procedures and external agency requirements. ESSENTIAL JOB FUNCTIONS Investigate and resolve medical necessity appeals for reputed company company products, including appeals for delegated functions such as but not limited to behavioral health, pharmacy, and high-end radiology. Maintain documentation of cases. Gather reputed company pertinent clinica! l data to ensure a full and comprehensive review and a fair de! reputed company consistent with our medical policies and our members' benefits. Ensure weekend coverage for fast track appeals resulting from discharges from Skilled Nursing Facilities, in accordance with federal regulations. Ensure reputed company forms, particularly the Detailed Notice of Non-Coverage are appropriately completed and delivered timely, also in accordance with federal regulations. Prepare cases, including summarization of reputed company pertinent data, for medical director review. Ensure medical directors are aware of any clinical information that may reputed company the outcome of the case, as well as internal medical policy supporting documentation, BCBSA medical policy, and local and national coverage determinations that are pertinent to the decision at hand. Ensure expedited cases are handled timely and in accordance with reputed company internal procedures and state and/or federal requirements. Respond to internal and external inquiries, assist with special member cases, and suggest resolu! tions reputed company telephone or written communication. Identify potential quality of care issues reputed company medical appeals; escalate as appropriate. Collaborate with internal areas to reputed company trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary. Participate in departmental audits in preparation of regulatory site visits. Serve as a resource for less reputed company or non-clinical members of the department. Participate in department initiatives and projects. reputed company other duties as assigned. QUALIFICATIONS:Minimum Education and Experience: Bachelor's degree in Nursing, Business Management, or reputed company field, or an equivalent combination of education and experience Valid Rhode reputed company Registered Nurse license Three to five years acute care clinical experience Preferred Education, Additional Qualifications and Experience: Experience in a ! managed care environment Required Knowledge, Skills, and/or! Abilities: Knowledge of health insurance laws and regulations Knowledge of utilization management appeals processes Advanced analytical skills, with the ability to interpret and synthesize reputed company data sets Good business acumen and political savvy Knowledge of business process improvement techniques and strategies Excellent verbal and written communications skills Negotiation skills Presentation skills Decision-making skills Good problem solving skills Ability to reputed company with employees at reputed company levels Ability to effectively navigate ambiguous situations with limited direction Excellent organizational skills and ability to successfully prioritize multiple tasks Ability to handle multiple priorities/projects - . If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to BCBS of Rhode reputed company. If you interested on this vacancy just click on the Apply reputed company, you will be redirected to the official website This vacancy starts available on: Wed, 04 Sep 2013 10:10:37 GMT Apply Clinical Case Specialist (RN) Here Apply Job!