Nurse Clinician (Clinical Denial Compliance)
BlueCross BlueShield of Tennessee - Chattanooga, TN

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Grade: BBPT 10

Range: $45,677 - $59,378 - $73,080

Hiring Manager: Alecia Cordell

Recruiter: Maria Renfro

General Summary

This position is accountable for comprehensive medical review of requests received through the regional ACD line, fax, web, mail, e-mail, or internally through customer service inquiries. Inquiries may be related to prior authorization requests, referred retrospective claims, claims to determine pre-existing status, UM appeals, provider appeals, member grievances, or special review requests. These positions utilize their professional training to ensure requests are reviewed in a manner consistent with member contracts, medical criteria and administrative policies and are responsible for participation in corporate programs, initiatives, and responding to inquiries from external sources.

Job Duties & Responsibilities

Performs comprehensive pre-existing reviews, reviews of rider-related diagnoses, potential misrepresentation referrals, rider related drug appeals, provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM precertifications and appeals, utilizing medical appropriateness criteria, nursing judgement, and contractual eligibility .

Performs thorough research and provides complete documentation for rationale to support determinations as well as specific written instructions regarding additional information necessary to complete the review.

Performs or participates in special studies or projects/pilots as directed by departmental management.

Cross functional and accomplished in all ancillary review functions.

May mentor/trains new incumbents and serve as a preceptor.

Seek the advice of the Medical Director when medical judgment is required.

Initiate referrals to accomplish discharge planning when such plans are evident at the time of the request e.g., telephone request for scheduled for total hip replacement.

Assist non-clinical staff in performance of administrative reviews.

Interact with Onsite and Case Management areas to ensure smooth transfer of member information across the continuum of care.

Apply established vendor protocols for authorization processes

Serves as a presentation guide for walk-through surveyors, auditors, group representatives, etc.

Position Specific Requirements – Clinical Denial Compliance

Duties & Responsibilities

The responsibility of this position will be to ensure that denial letters are compliant with all applicable regulatory and accrediting agencies including but not limited to the Grier Consent Decree, NQCA, URAC and the EPSDT and Newberry Consent Decrees.

Acquire information and clinical data as needed to review for appropriateness and medical necessity, routing to physician reviewers as appropriate.

Provides for accurate writing, logging and tracking of designated letters undergoing review in order to meet compliance with URAC, NCQA and the Contract Risk Agreement requirements.

Coordinates the review of problem cases, such as medical management, legal issues, claims requiring physician reviews and claims



Registered Nurse license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law required.

Bachelor's degree in nursing preferred.


Minimum 3 years varied clinical experience required.

Proficient knowledge and ability to apply various accreditation requirements (URAC, NCQA, etc.) preferred.

Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria preferred.


Ability to maintain professional and courteous internal communication with various departments, particularly Claims, in the exchange of information.

Must be PC literate with extensive knowledge of Windows and Microsoft Office. Must be able to pass Windows navigation test.

Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills.

Must be able to work independently and handle multiple tasks.

Customer service oriented

Must be adaptive to high pace and changing environment

Occasional weekend work may be required.

Position Specific Qualifications – Clinical Denial Compliance


Minimum 1 year Utilization Management experience is preferred.

VSHP TennCare Experience is preferred

Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills.

Must be able to work independently and handle multiple tasks

About this company
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BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....