CareFirst BlueCross BlueShield
Clinical Appeals Supervisor (Hybrid)
CareFirst BlueCross BlueShield, Baltimore, Maryland, United States, 21276
Clinical Appeals Supervisor (Hybrid)
CareFirst BlueCross BlueShield
Join to apply for the Clinical Appeals Supervisor (Hybrid) role at CareFirst BlueCross BlueShield.
Responsibilities
Provides direct supervision for the activities of assigned staff, ensuring appropriate and complete resolution of appeals and reconsiderations, including Regulatory complaints and External review requests.
Coordinates and/or conducts research, summarizes medical documentation and oversees the chronological presentation of plan handling to respond to regulatory complaints and to assist the Legal Department.
Responsible for development and oversight of the orientation and training of new and current associates, and assessment of department training needs.
Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the company.
Develops informative, educational and training presentations for internal and external stakeholders.
Supervisory Responsibility This position manages people.
Education Level High School Diploma or GED or, in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required.
Experience
5 years medical-surgical or similar clinical experience.
5 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield or a similar Managed Care organization or hospital.
Demonstrated leadership skills.
Preferred Qualifications
BS/MSN Degree
3 years supervisory experience
Knowledge, Skills and Abilities (KSAs)
Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
Knowledge and understanding of medical terminology.
Understanding of the appeals process and ability to work independently in researching complex issues.
Excellent analytical and problem solving skills are needed to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis.
Must be able to evaluate demands on a timely basis, establish and manage multiple priorities, and respond appropriately to unplanned events/projects.
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task in order to communicate effectively with internal and external customers.
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
CCM - Certified Case Manager Upon Hire Preferred
LNCC - Legal Nurse Consultant Certified Upon Hire Preferred
Salary Range $78,696 - $162,311
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
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.
Where To Apply Please visit our website to apply: www.carefirst.com/careers
Federal Disciplinary/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 U.S. Must be eligible to work in the U.S. without Sponsorship.
#J-18808-Ljbffr
Join to apply for the Clinical Appeals Supervisor (Hybrid) role at CareFirst BlueCross BlueShield.
Responsibilities
Provides direct supervision for the activities of assigned staff, ensuring appropriate and complete resolution of appeals and reconsiderations, including Regulatory complaints and External review requests.
Coordinates and/or conducts research, summarizes medical documentation and oversees the chronological presentation of plan handling to respond to regulatory complaints and to assist the Legal Department.
Responsible for development and oversight of the orientation and training of new and current associates, and assessment of department training needs.
Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the company.
Develops informative, educational and training presentations for internal and external stakeholders.
Supervisory Responsibility This position manages people.
Education Level High School Diploma or GED or, in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required.
Experience
5 years medical-surgical or similar clinical experience.
5 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield or a similar Managed Care organization or hospital.
Demonstrated leadership skills.
Preferred Qualifications
BS/MSN Degree
3 years supervisory experience
Knowledge, Skills and Abilities (KSAs)
Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
Knowledge and understanding of medical terminology.
Understanding of the appeals process and ability to work independently in researching complex issues.
Excellent analytical and problem solving skills are needed to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis.
Must be able to evaluate demands on a timely basis, establish and manage multiple priorities, and respond appropriately to unplanned events/projects.
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task in order to communicate effectively with internal and external customers.
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
CCM - Certified Case Manager Upon Hire Preferred
LNCC - Legal Nurse Consultant Certified Upon Hire Preferred
Salary Range $78,696 - $162,311
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
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.
Where To Apply Please visit our website to apply: www.carefirst.com/careers
Federal Disciplinary/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 U.S. Must be eligible to work in the U.S. without Sponsorship.
#J-18808-Ljbffr