ProvidenceRecruiter Since 2001
the smart solution for Providence jobs

Grievance & Appeals Nurse

Company: Blue Cross Blue Shield of Rhode Island
Location: Providence
Posted on: October 12, 2019

Job Description:


Job Description Collaborate with management to assist with the oversight and coordination of the research, negotiation, and resolution of member and provider complaints, grievances, and appeals for all products. Investigate and resolve medical necessity appeals on all company products. Ensure compliance with state and federal guidelines, including Centers for Medicare & Medicaid Services requirements. Maintain all appeals documentation according to external agency requirements. Act as a resource on the development, implementation, and maintenance of departmental policies, procedures, and programs. Assist in identifying, prioritizing, and implementing health plan opportunities for improvement in the areas of efficiency and effectiveness.

ESSENTIAL JOB FUNCTIONS:

  • Investigate and resolve medical necessity appeals for all company products. Maintain documentation of cases.
  • Collaborate with clinical lead to assist with the oversight and coordination of the research, negotiation, and resolution of escalated member and provider complaints, grievances, and appeals for all products.
  • Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication.
  • Identify potential quality-of-care issues within medical appeals; escalate as appropriate.
  • Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary. Represent the department at clinical workgroup meetings.
  • Participate in departmental audits in preparation of regulatory site visits.
  • Participate in department initiatives and projects.
  • Perform other duties as assigned.

    QUALIFICATIONS:

    Minimum Education and Experience:
    • Bachelor's degree in Nursing, Business Management, or related field; or an equivalent combination of education and experience.
    • Valid Rhode Island Registered Nurse license.
    • Three to five years of 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 complex 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 interface with employees at all 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.


          At Blue Cross & Blue Shield of Rhode Island (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, age, national origin or ancestry, disability, veteran status, sexual orientation, genetic information, sex, gender identity or expression, and any other personal attributes protected by federal, state, or local law. For more information about our commitment to diversity and inclusion, please see our Diversity Report at bcbsri.com/diversityreport .

          The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf to view the "EEO is the Law" poster.



          BCBSRI is committed to working with and providing reasonable accommodation to individuals with disabilities. If, because of a disability, you need a reasonable accommodation for any part of our application process, please contact us at (see application details) for assistance.

          During the application process, please allow a minimum of five business days before you contact our office to inquire about the status of your application. If you have any questions regarding your application or during the process, please contact Human Resources by phone at (see application details) or by email at (see application details) .

          Southern New England, Boston, MA, Hartford, CT, Health Data Analyst, RI Health Insurer, Healthcare, Wellness, Provider, Network, Rhode Island, RI, Care Management, Insurance, Acute, Registered Nurse, RN, Coordinator, Coordinate, BSN, Bachelor's Degree in Nursing, MSN, Master's

Keywords: Blue Cross Blue Shield of Rhode Island, Providence , Grievance & Appeals Nurse, Healthcare , Providence, Rhode Island

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Healthcare Jobs


PACU RNs, All shifts, Pre / Post Anesthesia - Travel (East Providence,
Description: PACU RNs, All shifts, Pre / Post Anesthesia Registered Nurses Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered (more...)
Company: HealthCare Traveler Jobs
Location: East Providence
Posted on: 10/24/2019

EP / Cath Lab Registered Nurses needed ASAP - Travel RN (East Providen
Description: Cath Lab / EP Lab Registered Nurses IAPB ECHMO Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered Nurses are (more...)
Company: HealthCare Traveler Jobs
Location: East Providence
Posted on: 10/24/2019

Orthopedics - Ortho Travel Nurse RN
Description: Nationwide Travel Nurse Jobs - Orthopedic RN--- Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for qualified registered (more...)
Company: HealthCare Travelers
Location: Plymouth
Posted on: 10/24/2019


OR Pediatric Surgery Travel Nurse RN
Description: Nationwide Travel Nurse Jobs - Pediatric Surgery RN Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for qualified (more...)
Company: HealthCare Travelers
Location: Plymouth
Posted on: 10/24/2019

Peds / Pediatric Registered Nurses Needed ASAP, Travel RNs (East Provi
Description: Pediatric Registered Nurses Peds RNs Days, Nights Weekends Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered (more...)
Company: HealthCare Traveler Jobs
Location: East Providence
Posted on: 10/24/2019

Registered Nurse Progressive Care Unit - Travel PCU RN (Leominster,MA)
Description: Progressive Care Registered Nurses PCU RNs Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered Nurses are one of (more...)
Company: HealthCare Traveler Jobs
Location: Leominster
Posted on: 10/24/2019

PICU RN, Pediatric Intensive Care Registered Nurse-Travel (Methuen,MA)
Description: PICU RNs Pediatric Intensive Care Unit Nurses Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered Nurses are one of (more...)
Company: HealthCare Traveler Jobs
Location: Methuen
Posted on: 10/24/2019

PACU RNs, All shifts, Pre / Post Anesthesia - Travel (Methuen,MA)
Description: PACU RNs, All shifts, Pre / Post Anesthesia Registered Nurses Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered (more...)
Company: HealthCare Traveler Jobs
Location: Methuen
Posted on: 10/24/2019

RN First Surgical Assistant - Travel RNFA
Description: Nationwide Travel Nurse Jobs - RNFA - RN First Surgical Assistant Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking (more...)
Company: HealthCare Travelers
Location: Plymouth
Posted on: 10/24/2019

Intensive Care Unit Nurse - ICU RN-Travel Assignments (Plymouth,MA)
Description: ICU RNs Intensive Care Unit Nurses Needed ASAP 8.13 26 week assignments Travel Registered Nurse Jobs AssignmentsThe Travel Nurse Season is here and it shows Registered Nurses are one of the disciplines (more...)
Company: HealthCare Traveler Jobs
Location: Plymouth
Posted on: 10/24/2019

Log In or Create An Account

Get the latest Rhode Island jobs by following @recnetRI on Twitter!

Providence RSS job feeds