Quality Of Care Review Nurse (Remote)

Resp & Qualifications

PURPOSE:
We are looking for an experienced Registered Nurse in Baltimore or surrounding counties who is willing and able to work largely remote. The incumbent may be expected to work at a CareFirst location based on business needs and work activities/deliverables upon request from their People Leader.The Quality-of-Care Nurse will effectively identify, prioritize, and respond to high level grievances, Quality of Care complaints, and complaint appeals from the member or member's authorized representative for Government Programs lines of business (Medicaid and Medicare Advantage). The incumbent reviews and interprets the grievance or complaint, medical and dental records, narrative notes, in-patient/office policies and all documentation submitted or collected by the plan pertinent to the issue. The incumbent will also understand the merits of legal and accreditation actions. The Quality-of-Care Nurse duties will include research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions (appeals). The Quality-of-Care Nurse will utilize clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the Quality of Care and the applicable appeal process for Government Programs lines of business in order to formulate a professional response to the Quality of Care or appeal request.

ESSENTIAL FUNCTIONS:

• Reviews all member grievances or complaints and complaint appeals concerning the Quality of Care provided by facilities or practitioners. Contacts members, providers, or other parties involved, as appropriate, verbally and in writing to obtain additional information regarding the complaint. Reviews medical and dental claims information and records, and member and provider correspondence to conduct patient care investigations and renders an investigative finding.
  
• Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.
  
• Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accreditation requirements while upholding corporate policies and decisions and meeting all State and Federal regulations and mandates. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from CMS and other Federal and State Regulatory Agencies.
  
• Provides detailed written and/or verbal responses to members, providers, and authorized representatives upon completion of a thorough investigation. Responds to follow up questions or concerns with members, providers, and other parties involved in the investigation, as appropriate.
  
Assists with the preparation of regulatory reports by detailing and summarizing the merits of legal or accreditation actions. Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

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QUALIFICATIONS:
Education Level: High School Diploma or GED.

Licenses/Certifications Upon Hire Required:
RN - Registered Nurse - State Licensure And/or Compact State Licensure Practice in MD, DC, VA, WV.
Experience: 5 years Clinical experience in direct health care or health insurance payor setting working with quality reporting, or analytics.
Preferred Qualifications:

• 3 years' experience in Quality Initiatives, Medical Review, Claims, Utilization Management or Case Management or similar Managed Care organization or hospital preferred.
  
• Working knowledge of NCQA standards.
  
• Bachelor's degree in Nursing.

Knowledge, Skills and Abilities (KSAs)

• Demonstrates excellent written and oral communication skills along with effective presentation skills. Able to provide verbal and written feedback for improvement. Must understand the appropriate mode of communication based on the subject matter.
  
• Computer proficiency and technical aptitude with the ability to utilize MS Office (Excel, Word and Outlook) and web based technology.
  
• Ability to exercise sound judgment in making critical decisions.
  
• Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
  
• Knowledge of patient rights and laws relative to those rights, such as HIPAA.
  
• Ability to effectively communicate and provide positive customer service to every internal and external customer.
  
• Proficient in standard medical practices and insurance benefit structures with the ability to use them in varied situation.
  
• 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 positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $69,768 - $138,567

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

MA and EGWP Appeals and Grievance

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

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

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