Appeals & Grievance Nurse Analyst

🔥 13 hours ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

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BlueCross BlueShield of Tennessee

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1952

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

BlueCross BlueShield of Tennessee is a leading health plan provider in Tennessee, serving 3. 4 million members. The company is committed to creating a workforce where everyone is valued, respected, and part of the team, emphasizing diversity and inclusion. They offer a range of career opportunities, including internships through their BlueBridge program, enabling new professionals to transition from college to work. BlueCross BlueShield of Tennessee also focuses on providing exceptional customer service and community care, striving to make a difference in the healthcare industry. It is an independent licensee of the Blue Cross Blue Shield Association and a qualified health plan issuer in the Health Insurance Marketplace.

📋 Description

• Review and process member and provider appeals • Ensure timely and accurate resolution in compliance with CMS, Medicare, and TennCare guidelines • Evaluate cases, determine next steps, and manage multiple priorities within strict turnaround times • Review clinical and medical records and summarize findings for Medical Director review • Research and document the substance and validity of appeals or quality-of-care grievances using multiple systems • Evaluate medical necessity documentation, including complex situations • Conduct outreach for clinical information as applicable • Prepare case files for Medical Director review • Create individualized member- and provider-specific appeal and quality-of-care grievance response letters • Assess response letters for accuracy and compliance and recommend improvements • Collaborate with clinical and non-clinical staff to resolve appeals and quality-of-care cases • Meet turnaround times as short as 24–72 hours

🎯 Requirements

• 3 years of clinical nursing experience required • Registered Nurse (RN) with active license in Tennessee, or an active license in the state of residence if participating in the Nurse Licensure Compact Law • Knowledge of Medicare, CMS, and TennCare regulations • Experience in appeals and grievance processes • Clinical knowledge • Strong analytical skills and attention to detail • Customer-focused approach • Case management skills • Accurate data entry • Proficiency in Microsoft Office (Outlook, Word, Excel, and PowerPoint) • Ability to work independently with minimal supervision or in a team environment • Ability to handle multiple projects • Excellent oral and written communication skills • Strong interpersonal and organizational skills • Ability to work a 40-hour week with flexibility for potential weekend coverage • Sponsorship is not available for this role

🏖️ Benefits

• Fully remote role • 40-hour workweek • Flexibility based on business needs • Potential weekend coverage • AI-enabled tools and proven workflows, templates, and policies to support everyday work