Independence Blue Cross - Philadelphia, PA

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About Our Company Independence Blue Cross is a pacesetter. With a dynamic commitment to innovation, the finest technology and a strong grounding in service to our community, we succeed by providing our people with an environment in which they can believe and thrive. Voted one of the best places to work in Pennsylvania four years in a row, Independence Blue Cross is moving forward, empowering change and defining excellence within the healthcare insurance industry. Job Summary Responsibilities Thoroughly investigates appeal requests.

Contacts member and providers to obtain information relative to the adverse determination. Collects all pertinent documents, including: denial letters; relevant medical policy; any additional clinical information from Care Management and Coordination, and requests medical records from practitioners as needed. Coordinates matched specialty medical reviews by independent physician consultants. Determines the appropriate medical specialty for each case at each level.

Documents all aspects of the investigative process, member and provider contracts, and other significant information in the Member Appeals System. Creates and updates written correspondence with members and providers. Prepares a case summary for Level 1 and Level 2 committee meetings. Acts as a clinical resource to determine if an appeal request is a medical necessity or benefit issue.

Maintains database on the status of all appeals to ensure compliance with multiple states' mandates. Performs other duties as needed Required Qualifications Must be a licensed Pennsylvania RN with a minimum of 5 years recent clinical experience, managed care experience is preferred. BSN preferred. Excellent interpersonal, verbal and written communication skills are essential.

Demonstrated PC and database experience preferred. Independence Blue Cross is an Equal Opportunity Employer (EOE). Qualified applicants are considered for employment without regard to age, race, color, religion, sex, national origin, sexual orientation, disability, or veteran status. Apply online by visiting and clicking on Job Opportunities Category: Clinical Specialist, Managerial

About this company
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Independence Blue Cross (IBC) provides health insurance and related services to some 2.2 million members in southeastern Pennsylvania and,...