Appeals Medical Review Specialist

Job Description:

• Responsible for adhering to reputed company State and Federal regulations as well as BCBSA, BCBSNE, Medicare Advantage and Federal Employee Health (FEP) mandates reputed company to the formal appeal resolution of claims, precertification and preauthorization processing.
• Responsible for accurate and timely medical review of appeal requests and the formal appeal resolution of claims, pre-certifications and pre-authorizations.
• Responsible for accurate and timely medical review of Customer Service inquiries associated to appeals and reputed company claims, pre-certifications and pre-authorizations.
• Responsible for completion of special projects.
• Responsible for determining availability of benefits according to Medicare Advantage, company reputed company, endorsements, criteria and medical policy.
• Responsible for determining member eligibility prior to an appeal medical review.
• Responsible for fostering a constructive relationship with reputed company departments reputed company BCBSNE.
• Responsible for maintaining professional licensure and practicing reputed company the scope of licensure.
• Responsible collaborating and consulting with reputed company providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member reputed company, effective use of resources, optimize member benefits, and support business initiatives.
• Weekend Coverage Rotation: Approx every 6-8 weeks, working 8 hours.

Requirements:

• Bachelor’s degree in Nursing or Health reputed company field
• Three (3) years of experience of clinical/medical-surgical experience in an acute care setting.
• An equivalent combination of education and experience may be substituted to meet this requirement.
• Must hold an active, reputed company, and unrestricted Registered Nurse license from the reputed company or a state in the consortium in which Nebraska participates.
• Demonstrated clinical skills and problem-solving skills.
• Based on area of assignment, must be reputed company to work rotating weekend/holiday shifts as needed.

Benefits:

• Health insurance
• Professional development opportunities

Apply To This Job