Blue Cross Blue Shield of North Dakota

Appeals and Clinical Research RN

Blue Cross Blue Shield of North Dakota

full-time

Posted on:

Location Type: Remote

Location: North Dakota • United States

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Salary

💰 $66,273 - $106,036 per year

About the role

  • 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.

Requirements

  • Associate's degree and completion of RN program. BSN is preferred.
  • 3+ years in appeals/clinical research, health insurance utilization/medical review, or related experience.
  • North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND.
  • Demonstrated nursing expertise with the ability to apply clinical knowledge to complex medical reviews, appeals, and policy interpretation.
  • Strong verbal and written communication skills, with the ability to clearly articulate clinical rationale to internal teams, providers, and leadership.
  • Sound decision‑making ability, including exercising professional judgment when interpreting medical policy, standards of practice, and clinical information.
  • Proven analytical thinking skills to evaluate complex clinical scenarios, identify patterns, and support accurate and consistent determinations.
  • Ability to conduct research and data analysis using clinical literature, medical policies, regulatory guidance, and internal resources to support decisions.
  • Strong prioritization and organizational skills, with the ability to manage multiple cases, meet deadlines, and adapt to shifting priorities in a fast‑paced environment.
  • Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards.
Benefits
  • Affordable medical, dental and vision coverage accepted throughout the United States
  • Employer funded Lifestyle Spending Accounts and Health Savings Accounts.
  • Voluntary employee contributions to Health Savings Accounts and Flexible Spending Accounts
  • Employer-paid life and disability insurance
  • 401(k) retirement plan with company match and immediate vesting
  • Paid holidays, paid time off (PTO), PTO donation program, and paid parental leave
  • Voluntary benefits including Accident, Hospital Indemnity, Critical Illness, Term/Whole Life, Cancer Care Insurance, and more.
  • Additional company perks
  • Robust mental health offerings including an Employee Assistance Program, Learn to Live, meQ.
  • Comprehensive learning and development opportunities and an Educational Assistance Program.
  • 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
  • Employee recognition, community initiative events and yearly company outings.
  • Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
  • Opportunities to connect through employee committees.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
clinical researchmedical reviewappeals processingpolicy interpretationdata analysisutilization studiesregulatory standardsmedical policiesnursing expertisedecision-making
Soft Skills
verbal communicationwritten communicationanalytical thinkingorganizational skillsprioritizationprofessional judgmentcollaborationadaptabilityeducation provisionpattern identification
Certifications
Registered Nurse (RN) LicenseAssociate's degreeBachelor of Science in Nursing (BSN)