Resolution Nurse

🔥 1 minute ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $29 - $54 / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

📋 Description

• Resolve complex clinical complaints, grievances, and appeals • Review documentation and interpret clinical-record data using clinical criteria and policies • Ensure compliance with regulatory and accreditation requirements for member and provider issues • Coordinate clinical resolution with internal and external clinician support • Document and summarize case results for involved parties • Provide complex clinical support for corporate, department, and special projects • Draft recommendations and communicate solutions concerning Complaints, Grievances, and Appeals • Identify, review, and analyze complex clinical issues involving corporate policies, procedures, and contracts • Consult with Management, Government Programs, group leaders, and other external contacts • Recommend improvements, updates, and clarifications to policies and procedures • Follow up on policy and procedure changes and initiate revisions to supporting documentation • Liaise with departments on cases requiring legal recommendations and direction • Serve as a clinical reference for Plan personnel regarding inquiries and applicable guidelines • Conduct peer reviews and document findings as assigned • Provide audit support, desk mentoring, and functional training for peers • Provide rotating on-call weekend and holiday coverage

🎯 Requirements

• Bachelor’s degree is required • RN Certification is required • Minimum of 5 years clinical experience • Working knowledge of Medicare C and D • Knowledge of URAC and NCQA standards for case management organizations • Knowledge of CMSA Standards of Practice for Complaints, Appeals, and Grievances • Knowledge of managed care principles and emerging health treatment modalities • Proficiency in Microsoft Word, Access, Excel, Outlook, and clinical databases • Ability to use a personal computer and talk-and-type documentation • Analytical, research, and organizational skills • Verbal and written communication skills • Project management skills and ability to manage multiple assignments • Ability to work independently and adjust to changing priorities • Ability to provide rotating on-call weekend and holiday coverage

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Retirement Plan • Paid Time Off • Holidays • Volunteer time off • Incentive Plan • Tuition Reimbursement • Flexible work environment • Training and continuing education • Professional and personal growth opportunities • Community volunteering opportunities