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 (reputed company), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's reputed company industry. reputed company is an equal opportunity, affirmative reputed company employer. We reputed company equal opportunities without reputed company to race, reputed company, religion, gender, age, national reputed company, disability, veteran status, sexual orientation... Clinical Case Specialist (RN) Location: reputed company Rhode reputed company reputed company: BCBS of Rhode reputed company is currently interviewing Clinical Case Specialist (RN) right now, this vacancy will be reputed company in Rhode reputed company. reputed company informations about this vacancy opportunity kindly read the reputed company below. At reputed company (reputed company), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of tod! ay's reputed company industry. reputed company is an equal opportunity, affirmative reputed company employer. We reputed company equal opportunities without reputed company to race, reputed company, religion, gender, age, national reputed company, disability, veteran status, sexual orientation, gender identity or reputed company. JOB reputed company Investigate and resolve medical necessity appeals on reputed company company products. Ensure compliance with state and federal guidelines, including Centers for Medicare and reputed company Services, US reputed company, RI Department of Health, and the reputed company reputed company as reputed company 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. reputed company 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 reputed company 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 reputed company, 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 reputed company 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 reputed company and in accordance with reputed company internal procedures and state and/or federal requirements. Respond to reputed company inquiries, assist with special member cases, and suggest resolu! tions reputed company telephone or written communication. Identify potential reputed company 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 reputed company. Serve as a resource for less reputed company or non-clinical members of the department. Participate in department initiatives and reputed company. 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 reputed company 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 reputed company Ability to effectively navigate ambiguous situations with limited direction Excellent organizational skills and ability to successfully prioritize multiple tasks Ability to handle multiple priorities/reputed company - . 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!