CareFirst BlueCross BlueShield
Clinical Appeals Supervisor (Hybrid)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
Job Overview
The
Clinical Appeals Supervisor (Hybrid)
directs and coordinates the accurate implementation of the clinical appeal process for members and providers who appeal on behalf of members for Government Programs lines of business. The incumbent will work a hybrid model, spending part of the week from home and part of the week at a CareFirst location based on business needs.
Responsibilities
Provides direct supervision for the activities of assigned staff, ensuring complete and timely resolution of appeals and reconsiderations, including regulatory complaints and external review requests.
Coordinates research, summarizes medical documentation and oversees presentation of plan handling to respond to regulatory complaints and assist the Legal Department.
Develops and oversees orientation and training of new and current associates, assigning tasks based on knowledge, skill sets, experience and development needs.
Identifies and researches comprehensive responses to problems, issues or concerns that have cross‑functional impact throughout the company.
Develops informative, educational and training presentations for internal and external stakeholders and supports quarterly reviews.
Qualifications
High School Diploma or GED. In lieu of a bachelor’s degree, an additional 4 years of relevant work experience is required.
5 years of medical‑surgical or similar clinical experience OR 5 years in Medical Review, Utilization Management or Case Management at a managed‑care organization or hospital.
Registered Nurse state licensure (required). Certified Case Manager and Legal Nurse Consultant certifications preferred.
BS/MSN degree preferred.
Government Programs Appeals & Grievances experience preferred.
Experience working in Guiding Care and Facets platforms and using MCG guidelines preferred.
Demonstrated knowledge of regulatory and accreditation requirements, appeals process and utilization management.
Excellent analytical, problem‑solving, verbal and written communication skills.
Ability to mentor and coach associates and manage multiple priorities.
Salary Range $78,696 - $162,311
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.
Where To Apply Please visit our website to apply:
www.carefirst.com/careers
#J-18808-Ljbffr
Clinical Appeals Supervisor (Hybrid)
directs and coordinates the accurate implementation of the clinical appeal process for members and providers who appeal on behalf of members for Government Programs lines of business. The incumbent will work a hybrid model, spending part of the week from home and part of the week at a CareFirst location based on business needs.
Responsibilities
Provides direct supervision for the activities of assigned staff, ensuring complete and timely resolution of appeals and reconsiderations, including regulatory complaints and external review requests.
Coordinates research, summarizes medical documentation and oversees presentation of plan handling to respond to regulatory complaints and assist the Legal Department.
Develops and oversees orientation and training of new and current associates, assigning tasks based on knowledge, skill sets, experience and development needs.
Identifies and researches comprehensive responses to problems, issues or concerns that have cross‑functional impact throughout the company.
Develops informative, educational and training presentations for internal and external stakeholders and supports quarterly reviews.
Qualifications
High School Diploma or GED. In lieu of a bachelor’s degree, an additional 4 years of relevant work experience is required.
5 years of medical‑surgical or similar clinical experience OR 5 years in Medical Review, Utilization Management or Case Management at a managed‑care organization or hospital.
Registered Nurse state licensure (required). Certified Case Manager and Legal Nurse Consultant certifications preferred.
BS/MSN degree preferred.
Government Programs Appeals & Grievances experience preferred.
Experience working in Guiding Care and Facets platforms and using MCG guidelines preferred.
Demonstrated knowledge of regulatory and accreditation requirements, appeals process and utilization management.
Excellent analytical, problem‑solving, verbal and written communication skills.
Ability to mentor and coach associates and manage multiple priorities.
Salary Range $78,696 - $162,311
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.
Where To Apply Please visit our website to apply:
www.carefirst.com/careers
#J-18808-Ljbffr