Medical Review and Appeals RN - Medical Review & Appeals, UM Programs at BCBSM in Detroit, Michigan

Job Description:

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.


• Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.


• Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. 


• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.


• Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.


• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.


• Identify and document quality of care issues; resolve or route appropriate area for resolution. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.


• Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.


• As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.


• Other duties may be assigned based on designated department assignment.

• Responsible for responding to BCBSM member level inquiries received from customer service, communicating the clinical information related to decisions our vendors make on our behalf for medical necessity. 


• Educate member services and members/providers on member benefits. 
  


• Assist with answering questions, supplying information and training on UM program (internally and externally).


• Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations. 
  


• Evaluate clinical documentation to resolve member inquires as to UM decisions and appeals/grievances. 


• Review claims issues pertaining to UM program to ensure correct reimbursement for covered/and or approved services, and resolve, and/or devise solutions to mitigate any gaps identified.


• Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services. 


• Work with cross functional teams to resolve issues/concerns/inquiries.


• Compile and report data based on member and provider inquiries.
  Registered Nurse with current unrestricted Michigan Registered Nurse license, Licensed Physical Therapist or Licensed Occupational Therapist required. 


• Extensive experience in post-acute (Skilled Nursing, Inpatient Rehab or Long-Term Acute Care) facilities.

• Bachelor's degree in nursing, allied health, business,
  or related field preferred.



• Two (2) to four (4) years of clinical experience which
  may include acute patient care, discharge planning, case management, and
  utilization review, etc.



• Seeking a registered nurse with Utilization management
  experience is preferred.



• Demonstrated clinical knowledge and experience relative
  to patient care and health care delivery processes.



• One (1) year health insurance plan experience or
  managed care environment preferred.



• Registered Nurse with current unrestricted Michigan
  Registered Nurse license required.



• Certification in Case Management may be preferred based
  upon designated department assignment.



• Excellent written and verbal communication skills.
  Excellent customer service and interpersonal skills.



• Working knowledge of current industry Microsoft Office
  Suite PC applications.



• Candidate should have experience with applying medical
  policy criteria to medical necessity reviews and knowledge of NCQA
  standards.



• Candidate will be responsible for performing medical
  necessity reviews and writing denial letters to enrollees in the health
  care plan and professional providers.



• Ability to apply clinical criteria/guidelines for
  medical necessity, setting/level of care and concurrent patient
  management.



• Knowledge of current standard medical
  procedures/practices and their application as well as current trends and
  developments in medicine and nursing, alternative care settings and levels
  of service.



• Knowledge of cost containment strategies, BCN/BCBSM
  policies and procedures, member benefits and community resources.



• Knowledge of applicable accreditation standards, local,
  state and federal regulations.



• Other related skills and/or abilities may be required
  to perform this job based upon designated department assignment.

• Clinical
  reviewers for this team are for professional providers only.

All qualified applicants will
receive consideration for employment without regard to, among other grounds,
race, color, religion, sex, national origin, sexual orientation, age, gender
identity, protected veteran status or status as an individual with a
disability.