QUALIFICATION REQUIREMENTS: Required: Registered Nurse licensed to practice in Maryland with a minimum of 3-5 years working, evaluating, and providing psychiatric or mental health services to individuals in a psychiatric setting including those who are at high risk of being a danger to themselves and/or the community, gravely disabled as a result of a mental disorder, have a co-occurring substance abuse disorder, or have related health care issues. A minimum of 2 years experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital or behavioral health field preferred.
Position requires excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members or patients with mental health treatment needs or those with substance abuse disorders and additions. Thorough knowledge of current standards of medical practice and insurance benefit structures.
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be able to evaluate demands on time and establish and manage appropriate priorities.
Must be able to respond with minimal supervisory input due to the nature of the call, requiring quick action.
Must maintain a ready command of a continuously expanding knowledge base of current medical and psychiatric practices and procedures, including current medical procedural terminology, surgical procedures, diagnostic entities and their complications.
Must maintain awareness of current legislation that impacts the appeal & grievance process.
Working knowledge of mainframe systems in order to access relevant information necessary for the review process and proficiency with Microsoft Word, Excel, LotusNotes, and various CareFirst dedicated software programs preferred.
Preferred: BSN/MSN Degree, or degree in related field, and Certified Case Manager (CCM) or Legal Nurse Consultant Certified (LNCC) certification.
Department: Clinical Appeals & Anlaysis
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 2/24/2018
Full Job Description at https://carefirstcareers.ttcportals.com/jobs/2440304-clinical-appeals-nurse-analyst-behavioral-health