Appeals & Grievance Nurse Analyst
B
BlueCross BlueShield of TennesseeHealthcare Administration
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 3 years
- Required Skills
- Microsoft OfficeAnalytical Skills
Requirements
- 3 years of clinical nursing experience.
- Registered Nurse (RN) with an active license in Tennessee or a state participating in the Nurse Licensure Compact Law.
- Proficient in Microsoft Office (Outlook, Word, Excel, and PowerPoint).
- Ability to work independently with minimal supervision or within a team.
- Strong analytical, organizational, and interpersonal skills.
- Excellent oral and written communication skills.
- Knowledge of Medicare, CMS, and TennCare regulations.
- Experience in appeals and grievance processes.
- Ability to handle multiple projects and strict turnaround times.
- Interest or experience in using AI tools such as Copilot.
Responsibilities
- Ensure timeliness and quality are met per regulations and guidelines.
- Utilize multiple systems to research and document the substance and validity of appeals or quality of care (QOC) grievances.
- Evaluate and research medical necessity documentation for clinical review, including complex situations.
- Conduct outreach for clinical information and prepare case files for Medical Director review.
- Create detailed member and provider-specific response letters for appeals and QOC grievances.
- Assess response letters for accuracy and compliance, providing recommendations for improvement.
- Work collaboratively with clinical and non-clinical staff for appropriate resolution of appeals and quality of care cases.
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