Researches and resolves standard and expedited member grievances related to the prospective, concurrent, or retrospective denial of services which include, but are not limited to, the following: Prior-authorization denials issued by BSC Medical Management or Pharmacy Services, delegated IPA/Medical Groups, and external vendors such as National Imaging Associates (NIA) and Mental Health Services Administrator.
Concurrent or retrospective utilization review denials of inpatient or outpatient care by internal or delegated entities.
Retrospective denial of claims by internal or external entities.
Analyzes and extracts pertinent clinical information from a variety of sources (internal and external); identifies applicable Blue Shield policies and guidelines, benefit provision, nationally recognized clinical criteria (Milliman, CMS) as well as criteria established by external vendors related to the grievance.
Prioritizes cases to meet internal timeframes, and all regulatory and accreditation standards
Collaborates with AGD Regulatory Team and BSC's Legal Department on complex member issues.
Communicates with members, providers, IPA/Medical Groups, internal and external parties throughout the appeals process.
Other duties as assigned.
Innovation and Complexity:
Responsible for providing feedback to improve processes, systems or products to enhance performance of the Appeals and Grievances Department.
Problems and issues faced are difficult and may require understanding of broader set of issues. Problems typically involve consideration of multiple issues, including but not limited to the concurrent, or retrospective denial of services. Typically solved through drawing from prior experience and analysis of issues. Develops new perspectives and approaches on existing problems.
Independently researches and resolves standard and expedited member appeals, in accordance with Blue Shield medical policies.
Analyzes and extracts pertinent clinical information from a variety of sources (internal and external).
Identifies applicable Blue Shield policies and guidelines, benefit provision, nationally recognized clinical criteria (Milliman, CMS) as well as criteria established by external vendors related to the grievance.
Knowledge and Experience:
Current active/unrestricted CA RN License.
Requires a college degree or equivalent years of experience. BSN is preferred.
Minimum of 5 years of prior relevant experience.
3 to 5 years Acute Care experience preferred.
Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.
Knowledge of preservice review, concurrent review, post service review preferred
Knowledge of HCPCS/CPT/Revenue codes and general coding principles.
Knowledge of claims processing rules/logic.
Strong analytical and problem-solving skills.
Requires advanced knowledge of Appeals and Grievances typically obtained through advanced education combined with experience.
Practical knowledge in Project Management.
Blue Shield Of California