Nurse Case Manager

3 days ago


Baltimore, Maryland, United States CareFirst BlueCross BlueShield Full time
Job Overview: We are seeking an experienced nurse to join our team as a Clinical Appeals Nurse. In this role, you will utilize your clinical skills and knowledge to research, analyze, and evaluate member and provider disputes related to adverse coverage decisions. Your strong communication skills and ability to navigate complex regulations will enable you to provide high-quality service to our members.

Responsibilities:
  • Investigate and respond to written appeals and reconsideration requests.
  • Compile and organize clinical, contractual, medical policy, and claims information for physician review.
  • Formulate recommendations for disposition and prepare the written case for review.

Qualifications:
  • Education: High School Diploma or GED
  • Licenses/Certifications:
    • RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required
    • CCM - Certified Case Manager Upon Hire Preferred
    • LNCC - Legal Nurse Consultant Certified Upon Hire Preferred
  • Experience:
    • 2 years medical-surgical or similar clinical experience OR 3 years' experience in mental health, psychiatric setting
    • Preferred Qualifications:
      • 2 years' experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital preferred.
      • BSN/MSN Degree. Government Program experience with Appeals and Grievance, Experience with MCG, InterQual, NCD and LCD's.

Salary Range: $66,960 - $132,990

Sponsorship in US: Must be eligible to work in the U.S. without Sponsorship.

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