申诉与投诉护士分析师
Appeals & Grievance Nurse Analyst
我们正在招聘BCBST的申诉与投诉护士分析师！
在这个职位中，您将审核和处理会员和提供者提交的申诉，确保在符合CMS、Medicare和TennCare指南的前提下及时准确地解决。您将评估案件，确定下一步行动，并在严格的时间限制内管理多个优先事项。
您还将审核临床和医疗记录，为医学总监的审核总结发现结果，并在最短24-72小时的时间内完成工作。您的工作将在保持监管合规性、改善会员体验以及通过详细的案例分析和有效使用数字工具支持高质量成果方面发挥关键作用。
要在这个职位上取得成功，您需要具备强大的分析能力、细致的关注点以及以客户为中心的方法。如果您了解Medicare、CMS和TennCare法规，并且有申诉和投诉流程的经验，将是强有力的候选人。临床知识、强大的数据录入准确性、案件管理技能，以及使用AI工具（如Copilot）提高效率的经验或兴趣，将进一步增强您的竞争力。
我们鼓励创新的文化。这包括负责任地使用AI驱动的工具来支持日常工作的开展——遵循经过验证的工作流程、模板和政策。随着职位的提升，我们期望员工更广泛地利用AI来改变我们服务会员的方式。
备注
• 此职位为全远程办公，每周工作40小时；根据业务需求，需要灵活安排，包括可能的周末值班
• 此职位不提供赞助
岗位职责
- 确保按照法规/指南的要求满足及时性和质量要求。
- 使用多个系统来适当研究和记录申诉或QOC投诉的内容和有效性。
- 评估并研究提交用于临床审查的医疗必要性文件，包括复杂情况。根据需要进行联系获取临床信息，并为医学总监准备案件文件。
- 制作详细的具体会员和提供者的申诉和QOC投诉回复信；评估申诉和QOC投诉回复信的准确性和合规性，并在需要时提供改进建议。
- 与临床和非临床员工协作，以适当解决申诉。
查看英文原文
We are hiring an Appeals & Grievance Nurse Analyst at BCBST!
In this role, you will review and process appeals submitted by members and providers, ensuring timely and accurate resolution in compliance with CMS, Medicare, and TennCare guidelines. You will evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
You will also review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours. Your work will play a critical role in maintaining regulatory compliance, improving member experience, and supporting high-quality outcomes through detailed case analysis and effective use of digital tools.
To be successful in this role, you’ll bring strong analytical skills, attention to detail, and a customer-focused approach. You will be a strong candidate if you have knowledge of Medicare, CMS, and TennCare regulations, along with experience in appeals and grievance processes. Clinical knowledge, strong data entry accuracy, case management skills, and experience (or interest) in using AI tools such as Copilot to improve efficiency will further strengthen your candidacy.
We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.
Note
• This is a fully remote role with a 40-hour workweek; flexibility is required based on business needs, including potential weekend coverage
• Sponsorship is not available for this role
Job Responsibilities
- Ensures timeliness and quality is met per regulations/guidelines.
- Utilize multiple systems in order to appropriately research and document the substance and validity of the appeal or QOC grievance.
- Evaluate and research medical necessity documentation submitted for clinical review including complex situations. Conduct outreach as applicable for clinical information and preparing case files for the Medical Director to review.
- Create detailed member and provider specific individualized appeal and QOC grievance response letters; assess appeal and QOC grievance response letters for accuracy and compliance as well as providing recommendations for improvement, if needed.
- Work collaboratively with the clinical and non-clinical staff for appropriate resolution of appeals and quality of care cases.
Job Qualifications
Experience
· 3 years - Clinical nursing experience required
Skills\Certifications
- Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Must be a team player, be organized and have the ability to handle multiple projects
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
License
· Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Number of Openings Available
1Worker Type:
EmployeeCompany:
BCBST BlueCross BlueShield of Tennessee, Inc.Applying for this job indicates your acknowledgement and understanding of the following statements:
BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.
Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
BCBST's EEO Policies/Notices
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.
Originally posted on Himalayas