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Resp & Qualifications
PURPOSE:
The Quality of Care Nurse will effectively identify, prioritize and respond to high level grievances, complaints and complaint appeals from the member or member's authorized representative for the Medicaid and Medicare Advantage lines of business. The incumbent reviews and interprets the grievance or complaint, medical and dental records, narrative notes, in-patient/office policies and all documentation submitted or collected by the plan pertinent to the issue. The incumbent will also understand the merits of legal and accreditation actions.
ESSENTIAL FUNCTIONS:
QUALIFICATIONS:
Education Level: High School Diploma or GED.
Experience: 5 years Clinical experience in direct health care or health insurance payor setting working with quality reporting, or analytics.
Preferred Qualifications:
Knowledge, Skills and Abilities (KSAs)
Licenses/Certifications
RN - Registered Nurse - State Licensure And/or Compact State Licensure Practice in MD, DC, VA, WV Upon Hire Required.
Salary Range: $69,768 - $138,567
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Quality and Accreditation (Mar)
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship.
#LI-CT1
Full Time
$93k-112k (estimate)
02/05/2024
07/08/2024
CAREFIRST.COM
Owings Mills, MD
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