Appeals Medical Review Specialist

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community. This position is accountable for performing appeals medical reviews to ensure correct dispositions according to all contracts, related endorsements, government regulations and BCBSNE medical policies. Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas. What you'll do: Responsible for adhering to all State and Federal regulations as well as BCBSA, BCBSNE, Medicare Advantage and Federal Employee Health (FEP) mandates related to the formal appeal resolution of claims, precertification and preauthorization processing. Responsible for accurate and timely medical review of appeal requests and the formal appeal resolution of claims, pre-certifications and pre-authorizations. Responsible for accurate and timely medical review of Customer Service inquiries associated to appeals and related claims, pre-certifications and pre-authorizations. Responsible for completion of special projects. Responsible for determining availability of benefits according to Medicare Advantage, company contracts, endorsements, criteria and medical policy. Responsible for determining member eligibility prior to an appeal medical review. Responsible for fostering a constructive relationship with all departments within BCBSNE. Responsible for maintaining professional licensure and practicing within the scope of licensure. Responsible collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives. Weekend Coverage Rotation: Approx every 6-8 weeks, working 8 hours. To be considered for this position, you must have: Bachelor’s degree in Nursing or Health related field Three (3) years of experience of clinical/medical-surgical experience in an acute care setting. An equivalent combination of education and experience may be substituted to meet this requirement. Must hold an active, current, and unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates. Demonstrated clinical skills and problem-solving skills. Based on area of assignment, must be able to work rotating weekend/holiday shifts as needed. The strongest candidates for this position will also possess: Demonstrated previous experience working in Medicare Advantage and Managed Care organizations. Experience in medical review or utilization management. Clinical experience in multiple levels of care. Knowledge of accreditation standards and regulatory requirements Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers. We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.