A & G Resolution Nurse RN

4 weeks ago

Harrisburg Pennsylvania, United States Capital Blue Cross Full time
Position Description:
Provides support to the Plan by providing resolution of complex clinical complaints, grievances and appeal. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes results to all parties involved in the case.

Responsibilities and Qualifications:
Duties and Responsibilities:

Represents the Plan by providing complex clinical support as needed for corporate, department and other special projects specific to Complaints, Grievance, and Appeals. Responsible for drafting recommendations concerning items impacting Complaints, Grievance, and Appeals and for communication and solution to issues.

Identifies, reviews and analyzes complex clinical issues regarding current corporate policies and procedures which are identified internally or through Complaints, Grievances, and Appeals. Reaches out to Management, Government Programs, and/or other external contacts (e.g., group leaders) to discuss questions and issues. Makes recommendations to improve, update and clarify any items that may require additional development/revision

Follows up on all policy and procedure changes to ensure implementation. Requests/initiates the revision of supporting documentation (e.g., policy manuals, procedure manuals, bulletins, etc.).

Functions as department liaison to resolve cases/issues that require legal recommendations and direction.

Provides point of clinical reference for Plan personnel to request and receive information concerning resolution of inquiries in accordance with guidelines - including CMS, NCQA, Provider Contracts, and the established Member Touchpoint Measures (MTM) at the level set by the National Blue Cross and Blue Shield Association to achieve quality performance goals set forth by all entities.

Takes action or makes recommendations to Management to improve service through interacting with other Plan personnel. Additionally the incumbent may: Conduct peer reviews and document findings as assigned; Provide audit support; Provide desk mentoring for new staff and staff undergoing cross-training; Provide functional training for peers, as required by workload.

Supports department by providing on-call weekend and vacation coverage on rotating basis.

Skills:

Ability to interact with other departments, as needed, to advise, educate and/or direct members to appropriate services

Demonstrated analytical, research and organizational skills in order to identify and analyze trends, discrepancies, and issues in reference to Plan policies, procedures and contracts

Demonstrated verbal communication skills, with the ability to express opinions and research findings to management personnel. Demonstrated written communication skills, with the ability to produce clear, thorough, and detailed letters, memos and reports regarding complex subject matter

Demonstrated project management skills, ability to manage multiple assignments, adjust to changing priorities and perform assignments independently

Familiar with the utilization of various software such as Microsoft Office Suite

Knowledge:

Knowledge of URAC and NCQA standards for case management organizations and CMSA Standards of Practice for Complaints, Appeals, and Grievances

Knowledge of managed care principles and emerging health treatment modalities. Ability to operate a personal computer (PC), including proficiency in Word, Access, Excel and Outlook and Clinical Databases utilizing a talk and type method of documentation

Experience:

Clinical experience to include working knowledge of both Commercial and Medicare lines of business is preferred.

Education and Certifications:

RN Certification is required

Associates or Bachelor’s degree is preferred

  • A & G Resolution Nurse RN

    5 days ago

    Harrisburg, PA, United States Blue Cross and Blue Shield Association Full time

    Position Description Provides support to the Plan by providing resolution of complex clinical complaints, grievances and appeal. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently...

  • Registered Nurse

    4 weeks ago

    Harrisburg, Pennsylvania, United States Senior LIFE Full time

    Overview: Weekend On-Call RN (Friday 4:30pm-Monday 8am)   Senior LIFE is an innovative home and community based Medicare and Medicaid funded program which provides all-inclusive healthcare services and support to seniors living in the community. Senior LIFE makes it possible for seniors to remain at home, enjoying the comfort and reassurance of familiar...

  • Registered Nurse

    3 weeks ago

    Harrisburg, Pennsylvania, United States Senior LIFE Full time

    Overview: Registered Nurse (RN)   “When the work that you do matters, it matters where you work”   10% increase in salary for bilingual (spanish/english) candidates   Newly Enhanced Health Care Benefit Package Available!   Senior LIFE is expanding our RN Home Care team! Become a part of an amazing group of healthcare professionals in the...

  • RN- Registered Nurse

    1 week ago

    Pennsylvania, United States Tekaccel Inc Full time

    Registered Nurse RN Location: Pennsylvania (Multi) Payrate: $51-$56 Per Hour Position Highlights: As a Registered Nurse - RN where you will change the lives of our patients and residents each day. Manage patient care by performing nursing assessments and collaborating with the nursing team, other disciplines, patients, and families to develop effective...

  • Registered Nurse

    5 days ago

    Harrisburg, United States Assist Medical Staffing Full time

    Hiring an Emergency Room Registered Nurse (RN) for a full time, 13 weeks contract position in Harrisburg, IL for a healthcare facility.The pay rate is $57 hr, weekly payFull time hoursHiring for shifts: NightsContract extensions availableTo do well in this role you should have your state Registered Nurse (RN) license and two years of relevant working...

  • Registered Nurse

    7 days ago

    Harrisburg, United States Assist Medical Staffing LLC Full time

    Job DescriptionJob DescriptionHiring an Emergency Room Registered Nurse (RN) for a full time, 13 weeks contract position in Harrisburg, IL for a healthcare facility.The pay rate is $57 hr, weekly pay.Full time hoursHiring for shifts: NightsContract extensions availableTo do well in this role you should have your state Registered Nurse (RN) license and two...

  • Dialysis Travel RN

    2 days ago

    Harrisburg, United States Quik Travel Staffing Full time

    Dialysis Travel Registered Nurse / RNThe Dialysis Travel Registered Nurse provides direct patient care for assigned patients and assists in care of other patients as needed.The Dialysis Travel Registered Nurse performs all technical aspects of dialysis procedures including:Assessing patient response to dialysis therapy.Making appropriate adjustments and...

  • Dialysis Travel RN

    2 days ago

    Harrisburg, United States Quik Travel Staffing Full time

    Dialysis Travel Registered Nurse / RNThe Dialysis Travel Registered Nurse provides direct patient care for assigned patients and assists in care of other patients as needed.The Dialysis Travel Registered Nurse performs all technical aspects of dialysis procedures including:Assessing patient response to dialysis therapy.Making appropriate adjustments and...

  • Registered Nurse

    3 days ago

    Harrisburg, United States Avera McKennan Hospital Careers Full time

    Join the RN Nursing team at Avera! Magnet Recognized:  Avera McKennan Hospital & University Health Center has received consecutive ANCC Magnet re-designations for meeting rigorous standards for nursing excellence and job satisfaction.Culture:  Be part of a multidisciplinary team built on teamwork, with compassion and the goal of Moving Health Forward for...

  • Registered Nurse

    6 days ago

    Harrisburg, United States Avera Prince of Peace-Skilled Nursing Full time

    Join the RN Nursing team at Avera! Love Where You Work:  Work at Avera where current employees rate their satisfaction at 94%. Join a team where the career opportunities are endless. Culture:  Be part of a multidisciplinary team built on teamwork, with compassion and the goal of Moving Health Forward for you and our...

  • Nurse (RN), BSN, Home Health

    2 days ago

    Harrisburg, United States UPMC - Pittsburgh Medical Center Full time

    Job DescriptionGrowing our UPMC Home Health Team in the Harrisburg area- Nurse (RN) BSN. Are you a nurse looking for a rewarding career where you can provide direct, one-on-one patient care? UPMC Home Healthcare is hiring caring, skilled, and compassionate registered nurse to join our home health nursing team! You’ll work in a home setting with a diverse...

  • REGISTERED NURSE(RN)

    3 weeks ago

    Pennsylvania Tpke, Pennsylvania, USA, United States MAS Medical Staffing Full time

    Seeking a(n) Registered Nurse (RN) professional with Registered Nurse () experience for a 3 week contract in the Langhorne PA area. MAS Medical Staffing offers rewarding travel opportunities to healthcare professionals throughout the United States. O Registered Nurse, Travel, Nurse, Registered, Healthcare, Staffing

  • REGISTERED NURSE(RN)

    3 weeks ago

    Pennsylvania Tpke, Pennsylvania, USA, United States MAS Medical Staffing Full time

    Seeking a(n) Registered Nurse (RN) professional with Registered Nurse () experience for a 2 week contract in the Langhorne PA area. MAS Medical Staffing offers rewarding travel opportunities to healthcare professionals throughout the United States. O Registered Nurse, Travel, Nurse, Registered, Healthcare, Staffing

  • Registered Nurse Supervisor

    1 week ago

    Pennsylvania, United States Peters Twp Nursing & Rehab Full time

    Evening shift RN Supervisor! 00 per hour! Nursing Student Loan Debt Repayment and Tuition Assistance *Tuition, Travel, and Wireless Service Discounts *Employee Assistance Program to support mental health *Employee Foundation to assist financially with unforeseen hardships *Health, Dental, Vision, Company-paid life insurance, 401K, Paid Time Off ...

  • Sous Chef

    4 weeks ago

    Pittsburgh, Pennsylvania, United States Bill's Bar & Burger Full time

    Overview: Benefits: Extensive and well-rounded training program Continued career development and growth opportunities Generous employee discounts on dining, retail, amusements, and hotels Multiple health benefit plans to suit your needs Dental, vision, voluntary life, short term disability, flexible spending accounts and 401 (k) Paid sick leave Paid...

  • RN- Registered Nurse

    4 days ago

    State of Pennsylvania, United States Tekaccel Inc Full time

    Registered Nurse RN Location: Pennsylvania (Multi) Payrate: $51-$56 Per Hour Position Highlights: As a Registered Nurse - RN where you will change the lives of our patients and residents each day. Manage patient care by performing nursing assessments and collaborating with the nursing team, other disciplines, patients, and families to develop...

  • RN Supervisor

    2 days ago

    Pennsylvania, United States Aventura at Terrace View Full time

    Immediately Hiring Night Registered Nurse (RN) Supervisor Top paying facility in the area Shift differentials! health dental wellness program including free telemedicine and increase take-home pay!!! Flexible scheduling for a work-life balance Assesses patients by physical examination including diagnostic testing to determine health status. ...

  • Project Manager I

    4 weeks ago

    York, Pennsylvania, United States Henkels & McCoy Full time

    Overview: Henkels & McCoy (H&M) is an industry-leading utility construction firm providing critical infrastructure design, construction, and maintenance services for the power, oil & gas pipeline, gas distribution, and communication markets throughout North America. Founded in 1923, H&M adapts nearly a century of experience to the dynamic infrastructure...

  • Full-Time Registered Nurse Supervisor

    2 weeks ago

    Pennsylvania, United States Glen Brook Rehabilitation and Nursing Full time

    5,000 Sign On Bonus!!! We are looking for a Full Time Registered Nurse Supervisor 3p-11p to join our Glen Brook Rehab Team! Come and join our "Dynamic Team” of Caring & Compassionate staff touching the lives of our residents. The Registered Nurse Supervisor will assist in directing and supervising the implementation of the resident care plan, including...

  • Registered Nurse

    2 weeks ago

    Pennsylvania, United States Frontline Healthcare Staffing Full time

    Join the team at a hospital located in *Pottstown Pennsylvania*! They are actively looking for a Registered Nurse (RN) specializing in PCU to join their incredible team!*About the Company:* The hospital is a 219 bed, acute care hospital offering an extensive range of services, including inpatient and outpatient, medical, surgical, diagnostic, emergency care,...