Grievance & Appeals Nurse
Company: Blue Cross Blue Shield of Rhode Island
Posted on: October 12, 2019
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
- 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
- Participate in department initiatives and projects.
- Perform other duties as assigned.
Minimum Education and Experience:
- Bachelor's degree in Nursing, Business Management, or related
field; or an equivalent combination of education and
- 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
- 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
- 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
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
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)
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
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