Responsibilities
- Initiate referrals to ensure appropriate coordination of care.
Seek the advice of the Medical Director when appropriate, according to policy.
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
Occasional weekend work may be required.
Must be able to pass Windows navigation test.
Testing/Assessments will be required for Digital positions.
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.
Requirements
- License: Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Experience: 3 years - Clinical experience required
Skills\Certifications: Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Working knowledge of URAC, NCQA and CMS accreditations
Must be able to work in an independent and creative manner.
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Superior interpersonal, client relations and problem-solving skills
Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria
About BlueCross BlueShield of Tennessee
As Tennessee's largest health plan, we've been helping Tennesseans find their own unique paths to good health for more than 70 years. More than that, we're your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.
Our mission is simple: peace of mind through better health.
We're an independent, not-for-profit, locally governed health plan company – meaning we live and work alongside our Tennessee business customers and plan members. Our 6,000 employees across the state have built our strong reputation for integrity, excellent service and community leadership.
But we are also part of the BlueCross BlueShield Association, a nationwide association of health care plans. Because of this, our plan members have access to the same quality health benefits while traveling or living out of state that they have while in Tennessee.
