Blue Cross Blue Shield of North Dakota

Clinical Research

• Reviews and makes appropriate appeal determinations according to applicable appeal policies and procedures, medical policies, reimbursement policies, and coding policies.
• Handles emergent and standard appeal requests and makes appropriate determinations using medical knowledge, judgement, expertise, and interpretation of medical policy and standards of practice.
• Prepares cases for review by the Medical Director so a final determination can be made.
• Ensures providers and members are notified on all emergent case types.
• Identifies patterns and practices within the organization.
• Assists in analyzing and reporting of appeals data.
• Provides education on appeals processes to areas of the organization as appropriate.
• Reviews existing medical policies and develops new policies in collaboration with Medical Directors and Medical Policy Leadership.
• Identifies trends that may need to be addressed in policy and works collaboratively with leadership to incorporate them as appropriate.
• Assists with appropriate research needed including regulatory standards, standards of practice, utilization studies, plan surveys, literature research, and consultants.
• Serves as a clinical point of contact for the organization for numerous internal parties.
• Participates in various projects and workgroups within the organization.
• Researches complex clinical issues and internal resources including benefit matrix, benefit plans, policies, and external sources which may impact claims.

Appeals and Clinical Research RN