Job Description

Reviews provider appeals to ensure medical necessity and experimental/investigational claims were processed correctly according to multiple coverage guidelines. Makes final determination based on findings and procedures within strict timelines established by regulatory requirements. Authors within final document to provider appropriate statement supporting final determination.

Job duties include but are not limited to:

• Reviews and researches provider appeals to reach a final determination
• Reviews provider appeal and medical documentation
• Reviews form CMS-1500 or equivalent electronic counterpart for proper coding
• Accesses Legacy or Diamond to review how claim was originally processed by BCBSF
• Assist appeal coordinators in the clinical research and processing of appeals in accordance with Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), and corporate / departmental standards

Interpret BCBSF Medical Coverage Guidelines for staff

• Collaborate with Managing Medical Director to facilitate changes to BCBSF Medical Coverage guidelines
• Responsible for research, preparation, and presentation of clinical appeal cases (medical necessity and experimental/investigational procedures) to the Provider Appeal Panel
• Works with business partners across the organization, as needed, to gather data as input for final determination
• Follows regulatory requirements as appropriate and corporate values, policies and procedures
• Ensures final determination is reached and communicated to provider within strict timelines
• Documents findings and renders final determination in various BCBSF systems and SQL databases
• Creates appropriate statement within final document to provider that supports final determination

Job Requirements:

• 2+ years related work experience. Experience Details: Clinical experience
• Related Bachelor’s degree or additional related equivalent work experience
• RN - Registered Nurse - State Licensure and/or Compact State Licensure State of Florida
• Licensed Registered Nurse
• Demonstrated extensive experience with Medical Coverage Guidelines as it relates to medical necessity and experimental/investigational procedures
• Demonstrated ability to interact with internal and external customers in a highly professional manner
• Demonstrated ability to simultaneously interact with multiple research and processing systems
• Knowledge of HIPAA and ERISA requirements
• Knowledge of regulatory requirements
• Ability to work within strict timeframes
• Ability to use Microsoft Office, e.g., Word, PowerPoint, Excel

Preferred:

• Minimum of two years of bedside clinical experience in a hospital setting
• At least one year of experience in clinical appeals or utilization management
• Strong understanding of ICD-10 coding principles
• Excellent written communication skills, with the ability to articulate complex clinical information in a clear and professional manner for appeal justifications
• Exceptional critical thinking and problem-solving skills
• Ability to use BCBSF systems, e.g., Legacy, Diamond, Siebel, PIP, TSO, CMCA, FAM, Convergence, Network Contracting and 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.

This position offers a hybrid work arrangement which combines flexibility with in-office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate or regional offices may be required.

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.