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Appeals and Clinical Research RN

4 weeks ago

Fargo, United States Blue Cross Blue Shield Full time

You likely know us as an insurance company, but that’s just a portion of what we do. Hundreds of thousands of North Dakotans trust us to provide them with personalized service and unmatched access to care. It’s a mission we take seriously.

We also work with entities throughout the state to challenge the cost and complexity of health care in North Dakota. This uncompromising goal requires caring, innovative people who are ready and willing to help create a new level of health and well-being in North Dakota and beyond.

Work environment

This opportunity is open to a remote, hybrid or an in-office working arrangement. We empower our employees to find a work style that is best for them. Learn more at Life at Blue | BCBSND.

Pay information

  • Pay Level: 023
  • FLSA Category: Exempt – Salaried
  • Individual pay will be based on skills, experience, qualifications, location, internal equity, and other relevant factors.
  • Opportunities for continued salary growth through a performance-based merit program.

A day in the life 

The Appeals and Clinical Research RN is responsible for the appeals review and assists in the oversight of the appeals policies and procedures for Blue Cross Blue Shield North Dakota (BCBSND). This role ensures processes are in compliance with state and federal regulations along with all other quality standards, accreditations and certifications. This role is responsible for providing research, support, and recommendations for medical policy development. Through the review and appeals determination process, this role provides education to appropriate parties regarding proper appeal processes to ensure accuracy and consistency of processes and procedures throughout the company.

Your responsibilities will include 

  • Reviews and makes appropriate appeal determinations according to applicable appeal policies and procedures and medical policy.
  • Handles emergent and standard appeal requests and makes appropriate determinations using medical knowledge, judgement, expertise, and interpretation of medical policy and standards of practice.
  • Prepares cases for review by the Medical Director so a final determination can be made. Ensures providers and members are notified on all emergent case types.
  • Identifies patterns and practices within the organization. Assists in analyzing and reporting of appeals data.
  • Provides education on appeals processes to areas of the organization as appropriate.
  • Reviews existing medical policies and develops new policies in collaboration with Medical Directors and Medical Policy Leadership. Identifies trends that may need to be addressed in policy and works collaboratively with leadership to incorporate them as appropriate. Assists with appropriate research needed including regulatory standards, standards of practice, utilization studies, plan surveys, literature research and consultants.
  • Serves as a clinical point of contact for the organization for numerous internal parties.
  • Participates in various projects and workgroups within the organization.
  • Researches complex clinical issues and internal resources including benefit matrix, benefit plans, polices and external sources which may impact claims.

What you need to succeed 

  • An Associate's/Bachelor's degree in Nursing or the completion of an RN program.
  • Minimum of 3 years of appeals/clinical research, health insurance utilization/medical review or related experience is required.
  • An RN license valid for work in the state of North Dakota or a compact RN license. 
  • Clearly communicate with team members on the team and in other departments to research and analyze varying cases.
  • An ability to prioritize and organize work with varying timelines for cases and daily work.

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Benefits

  • Affordable medical, dental and vision coverage accepted throughout the United States
  • Employer funded Lifestyle Spending Accounts, Health Savings Accounts and Health Reimbursement Arrangements
  • Employer-paid life and disability insurance
  • 401(k) retirement plan with company match and immediate vesting
  • Paid holidays, paid time off (PTO), PTO donation program, and paid parental leave
  • Voluntary benefits including Accident, Hospital Indemnity, Critical Illness, Term/Whole Life, Cancer Care Insurance, and more.

Additional company perks

  • Robust mental health offerings including an Employee Assistance Program, Learn to Live, meQ.
  • Comprehensive learning and development opportunities and an Educational Assistance Program.
  • 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
  • Employee recognition, community initiative events and yearly company outings.
  • Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
  • Opportunities to connect through employee committees.

Equal opportunity employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com.