Medicare Appeals RN

Job Summary
Appeals & Post Service Review RN role is centered on the daily case review for appeals from members, members' beneficiary representatives, and providers in order to meet timeliness & documentation compliance metrics. In addition, the role also is responsible for post service review and clinical provider appeals. Facilitates final determination based on findings and procedures within strict timelines established by regulatory requirements. Authors final appropriate statement supporting final determination based on appropriate criteria or medical director determination.

Essential Functions

The essential functions listed represent the major duties of this role, additional duties may be assigned.

• Reviews and researches appeals to reach timely, appropriate determination.

• Reviews and researches member and provider appeals and their medical documentation, abstracts pertinent data into the documentation system, and reviews with Medical Director to reach a final determination.

• Processes Post Service reviews, abstracts pertinent data into the documentation system, reviews with Medical Director, as appropriate, to reach determination.

• Accesses Legacy or Diamond to review how claim was originally processed as needed.

• Interpret BCBSF Medical Coverage Guidelines for staff.

• Responsible for research, preparation, and presentation of clinical appeal cases (medical necessity and experimental/investigational procedures).

• Works with business partners across the organization, as needed, to gather data as input for final determination.

• Prepares Independent Review Entity (Maximus) packages and assists team members with case review to ensure all documentation is included in the package.

• Follows regulatory requirements as appropriate and corporate values, policies and procedures.

• Ensures final determination is reached and communicated within strict timelines

Qualifications

• 2+ years of clinical experience in a related field
• Bachelor's degree in a related field or equivalent work experience
• Current State of Florida Licensed Registered Nurse (RN) with unrestricted licensure or Compact State Licensure
• Proven experience with Medical Coverage Guidelines, including medical necessity and experimental/investigational procedures
• Excellent communication skills for interacting with internal and external customers
• Ability to multitask and navigate multiple research and processing systems simultaneously
• Familiarity with HIPAA and ERISA requirements
• Knowledge of regulatory requirements
• Ability to work under tight deadlines
• Proficiency in Microsoft Office (Word, PowerPoint, Excel)

Preferred Qualifications

• Experience with BCBSF systems, including:
  • Legacy
  • Diamond
  • Siebel
  • PIP
  • TSO
  • CMCA
  • FAM
  • Convergence
  • Network Contracting
  • Medical Coverage Guidelines
• Knowledge of BCBSFL policies and procedures

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer:
As a Florida Blue employee, you will be at the heart of GuideWell's vision - to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan including employer match;
• Paid time off, volunteer time off, 10 holidays and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $71,200 - $115,700

Typical Annualized Hiring Range: $71,200 - $89,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.