Get ready to interview in Richardson on May 15th, 16th, and 17th!
We are the Health Care Management division of HCSC — a team of dedicated nurses, doctors and other clinicians. Everything we do, and every decision we make, aims to help our members live their most healthy lives. We treat the whole person with integrated pharmacy, physical and mental health care benefits.
We’re also tackling the social determinants of health by creating non-clinical partnerships in the communities where we work and live, because everyone should have access to quality health care. We use innovative tools and approaches to help members get the most out of their plan benefits, as affordably as possible. We are more than a health care insurer and we are truly anchored in our purpose: to do everything in our power to stand by our members in sickness and in health.
This position is responsible supervising staff handling the appeals process for behavioral health provider and member appeals activity, including ensuring appeals are meeting quality standards and regulatory mandates, accreditation standards and departmental policies and procedures. Develop appeals policies, procedures, standards, metrics, and reporting for the Behavioral Health Appeals department.
Registered Nurse (RN) or Masters-level Behavioral Health Professional with current license in good standings (independent practice license if BH Professional) in the state of operations.
3 years with behavioral health claims or appeals.
Knowledge of state and federal utilization review and appeal regulations, national accreditation standards including NCQA, URAC, and Department of Insurance.
Report creation experience.
Experience working across departments to resolve issues.
Verbal and written communication skills to oversee and motivate employees, interface across the division or across the enterprise, and represent the company to members and physicians.
PC experience and proficiency in Microsoft Office and healthcare databases.
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma, Texas and several subsidiaries are part of the largest customer-owned health benefits company in the United States and fourth largest overall. We offer a full range of managed care programs for individuals, families, employer groups and Medicare beneficiaries. And we focus on improving the health and wellness of our members and communities by: offering a variety of health insurance and wellness products to employers and individuals; keeping our focus local; participating in our communities in meaningful ways such as Blue Corps employee volunteer program and our Healthy Kids, Healthy Families initiative. The commitment of our employees to providing superior services and products has made us one of the fastest growing health care insurance companies in the nation. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability, or protected veteran status.