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Blue Cross and Blue Shield of Vermont Clinical Review Registered Nurse in Berlin, Vermont

This job was posted by https://www.vermontjoblink.com : For more information, please see: https://www.vermontjoblink.com/ada/r/jobs/711813

Blue Cross and Blue Shield of Vermont is looking for a Clinical Review Registered Nurse to join our Utilization Management team. Our company culture is built on an unwavering focus on our members and giving them the best service possible. We offer a balanced, flexible workplace, an onsite gym (post-COVID), fitness and wellness programs, a competitive salary and full benefits package including medical and dental insurance, vision, 401k, paid time off and holidays, and resources to support your ongoing personal and professional growth and development.


Clinical Review Registered Nurse Primary Responsibilities:


+ Conduct clinical reviews of all prior approval, post service reviews, customer service and claims requests. Determine adequacy of clinical elements of clinical information submitted. Make determinations based on medical policy, evidence-based guidelines, and medical necessity.


+ Communicate directly with requesting providers to obtain additional clinical information as needed in order to make utilization management decisions.


+ Review late and out of network prior approval / referral authorizations for appropriateness and make determination on benefit level based on medical necessity.


+ Provide timely and accurate review for procedure/service appropriateness, reconsideration, and appeals based on Rule 9-03, DRF, and NCQA Standards.


+ Participate in medical policy committee including research and development of policies and collaboration with participating provider.


+ Determine through clinical review members that would potentially benefit from case management. Initiate referrals to triage to assess these members for effective case management intervention.


Clinical Review Registered Nurse Benefits:


+ Health insurance (including vision)


+ Dental coverage (free to employees)


+ Wellness Program


+ 401(k) with employer match


+ Life Insurance


+ Disability Insurance


+ Combined time off (CTO) – 24 days per year + 8 paid holidays


+ Tuition Reimbursement


*full job description attached to ADP posting

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