Responsible for adhering to all State and Federal regulations as well as BCBSA, BCBSNE, Medicare Advantage and Federal Employee Health (FEP) mandates related to the formal appeal resolution of claims, precertification and preauthorization processing.
Responsible for accurate and timely medical review of appeal requests and the formal appeal resolution of claims, pre-certifications and pre-authorizations.
Responsible for accurate and timely medical review of Customer Service inquiries associated to appeals and related claims, pre-certifications and pre-authorizations.
Responsible for completion of special projects.
Responsible for determining availability of benefits according to Medicare Advantage, company contracts, endorsements, criteria and medical policy.
Responsible for determining member eligibility prior to an appeal medical review.
Responsible for fostering a constructive relationship with all departments within BCBSNE.
Responsible for maintaining professional licensure and practicing within the scope of licensure.
Responsible collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.
Weekend Coverage Rotation: Approx every 6-8 weeks, working 8 hours.

Bachelor’s degree in Nursing or Health related field
Three (3) years of experience of clinical/medical-surgical experience in an acute care setting.
An equivalent combination of education and experience may be substituted to meet this requirement.
Must hold an active, current, and unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates.
Demonstrated clinical skills and problem-solving skills.
Based on area of assignment, must be able to work rotating weekend/holiday shifts as needed.

Appeals Medical Review Specialist

About this role