Job Responsibilities

Initiate referrals to ensure appropriate coordination of care.Seek the advice of the Medical Director when appropriate, according to policy.Assists non-clinical staff in performance of administrative reviewsPerforming comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.Occasional weekend work may be required.Must be able to pass Windows navigation test.Testing/Assessments will be required for Digital positions.Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.

Job Qualifications

License

Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

3 years - Clinical experience required

Skills\Certifications

Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)Working knowledge of URAC, NCQA and CMS accreditationsMust be able to work in an independent and creative manner.Excellent oral and written communication skillsStrong interpersonal and organizational skillsAbility to manage multiple projects and prioritiesAdaptive to high pace and changing environmentCustomer service orientedSuperior interpersonal, client relations and problem-solving skillsProficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria

Weekend/Holiday Shifts Required.

Saturday and Sunday and holidays that fall on the weekends with flexibility for the days worked during the week.

Compressed Work Week option available: 4 days x 10 hour shifts.

The weekend employee will work holidays that fall on the weekend.  If they choose to work a Compressed Work Week, holiday weeks will be 8 hour shifts per Enterprise policy.

Number of Openings Available:

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test.  An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine  and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.