Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Working knowledge of URAC, NCQA and CMS accreditations
Must be able to work in an independent and creative manner.
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Superior interpersonal, client relations and problem-solving skills
Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Applying for this job indicates your acknowledgement and understanding of the following statements:
Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
BCBST's EEO Policies/Notices
Benefits
Paid time off
Additional Information
Job Responsibilities
Initiate referrals to ensure appropriate coordination of care.
Seek the advice of the Medical Director when appropriate, according to policy.
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
Occasional weekend work may be required.
Must be able to pass Windows navigation test.
Testing/Assessments will be required for Digital positions.
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.
Job Qualifications
License
Registered Nurse (RN) with active 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.
Bcbst · TN, Chattanooga, Remote