Temporary GAU RN

At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

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 and 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.

Investigate and resolve medical necessity appeals for all company products. Maintain documentation of cases. Collaborate 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.