Search for Jobs

49 Results
CareFirst, Inc.
Baltimore, MD, United States (on-site)
22 hours ago
CareFirst, Inc.
Baltimore, MD, United States (on-site)
22 hours ago
CareFirst, Inc.
Baltimore, MD, United States (on-site)
22 hours ago
CareFirst, Inc.
Baltimore, MD, United States (on-site)
22 hours ago
WellSpan Health
Thurmont, MD, United States (on-site)
23 hours ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
1 day ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
2 days ago
Holy Cross Health Partners | Holy Cross Health
Kensington, MD, United States (on-site)
2 days ago
CareFirst, Inc.
Baltimore, MD, United States (on-site)
2 days ago
Tidal Health
Salisbury, MD, United States (on-site)
2 days ago
Tidal Health
Salisbury, MD, United States (on-site)
2 days ago
Tidal Health
Salisbury, MD, United States (on-site)
2 days ago
Tidal Health
Salisbury, MD, United States (on-site)
2 days ago
CareFirst, Inc.
Baltimore, MD, United States (on-site)
2 days ago
LifeStance Health
Annapolis, MD, United States (on-site)
2 days ago
Johns Hopkins University
Baltimore, MD, United States (on-site)
4 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
4 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
4 days ago
Johns Hopkins University
Baltimore, MD, United States (on-site)
5 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
5 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
5 days ago
Johns Hopkins University
Baltimore, MD, United States (on-site)
5 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
5 days ago
University of Maryland, Baltimore
Baltimore, MD, United States (on-site)
5 days ago
Johns Hopkins University
Baltimore, MD, United States (on-site)
5 days ago
1 - 25 Results of 49
CareFirst, Inc.
Baltimore, Maryland, United States (on-site)
22 hours ago

Description

Resp & Qualifications

PURPOSE:
The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional to work remotely from within the Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business related activities.

ESSENTIAL FUNCTIONS:
  • Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
  • Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.
  • Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accredidation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS.
  • Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.


QUALIFICATIONS:

Education Level: High School Diploma

Experience: 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting.

Preferred Qualifications:
  • 2 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred.
  • BSN/MSN Degree.


Knowledge, Skills and Abilities (KSAs)
  • Knowledge and understanding of medical terminology.
  • Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
  • Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task.
  • Ability to effectively communicate and provide positive customer service to every internal and external customer.
  • Knowledge of Microsoft Office programs.
  • Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions.


Licenses/Certifications:
  • RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required.
  • CCM - Certified Case Manager OR LNCC - Legal Nurse Consultant Certified Upon Hire Preferred.

Department

Department: Clinical Appeals and Analysis

Equal Employment Opportunity

CareFirst 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.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: 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 US

Must be eligible to work in the U.S. without Sponsorship.

#LI-SS1

Job Information

  • Job ID: 68017103
  • Workplace Type: On-Site
  • Location:
    Baltimore, Maryland, United States
  • Company Name For Job: CareFirst, Inc.
  • Position Title: Nurse, Clinical Appeals (Remote)
  • Job Function: Other
  • Job Type: Full-Time
Insurance
Owings Mills , MD , US

At CareFirst BlueCross BlueShield, we’re building the future of healthcare with the widest coverage and the largest network for medical, dental and vision insurance in Maryland, Washington, D.C. and Northern Virginia. Every day, we make a meaningful difference in the communities where we both live and work. We solve real problems for the people we serve with equal parts empathy and urgency-simplifying the complex, delivering tailored solutions and stepping forward with new ideas. Join an inspired, collaborative team that's b...

View Full Profile

Jobs You May Like
Filters
Workplace Type
Job Function
Industry
State