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 pre-certifications 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 Duties & Responsibilities
Utilize Grier for decision making
Utilize the TennCare rules for decision making
Utilize the Bureau of TennCare medical necessity definition in decision making
CMS guideline use in decision making
Performs Medical Management and Utilization Management duties
Registered Nurse 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 - VSHP
Milliman's Certification Preferred. Must be willing to obtain within 1 year from date of hire.
Position requires 24 months in role before eligible to post for other internal positions
BlueCross BlueShield of Tennessee - 21 months ago
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....