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.

Essential functions:

• Reviews and researches provider appeal 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.

Requirements:

• 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.
• 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.

Experience:

• 2+ years related work experience or equivalent combination of transferable experience and education Clinical experience

Education:

• Related Bachelor’s degree or additional related equivalent work experience

Qualifications/Certificates:

• State of Florida Licensed Registered Nurse
• Nursing\RN
• Registered Nurse
• State Licensure And/or Compact State Licensure