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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

Position:  Review Analyst R.N. -I
Reports To: 
Division:  BANA Medical Audit&Review (2117)
Company:  ABCBS
Location:  Label
Job Code:  39601X
Min Salary:   52100
Date Posted:  10/12/2012

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Position Specific Requirements: None

Job Summary
This position is accountable for reviewing claims for the Enterprise for Blue Advantage National Accounts (BANA) line of business for the purpose of resolving medical, contractual, or technical issues/questions by applying corporate and medical guidelines and policies.

Nature & Scope

In order to enable the company to continue to meet the needs of its customers in a changing and competitive marketplace, the Review Registered Nurse Analyst is required to adapt to constantly updated medical and enterprise procedures, policies, and contracts. The organizational environment is one of teamwork and supportive relationships with team members.


This position receives claims to be reviewed directly from the UR Researcher. These are claims for the claims processing areas for Blue Advantage National Accounts.  This position also receives written or oral inquiries from Customer Service, the regional offices, providers, and members.


The incumbent's work is primarily guided by any claims referred for review by the any claims editing system, CodeReview, Claims Processing, or Customer Service. The incumbent must be self-directed and make active attempts to influence events to achieve goals. He/She must have the ability of prioritize and make sound judgments.


The challenges of this position are centered around the incumbent's ability to properly define the direction in which to proceed with all areas related to the prepayment review of claims. The incumbent is also challenged with planning and organizing projects assigned directly to this position for completion within established timeframes.


The incumbent's contacts within the enterprise include: Professional and clerical staff of all Medical and Audit Review Division teams -- for the coordination, processing, and completion of work assignments and projects; Corporate Medical Director -- for implementation of and clarification of Corporate Medical Policy and its application to claims review; Claims Processing - to assure proper adjudication of claims; Legal - to assist in the review of appeals or other legal actions; and Customer Service - to provide assistance in re-reviews generated by provider or member questions. The incumbent also interfaces with claims analysts for the purpose of gathering information for projects. Provider contacts are made by the incumbent to obtain information and coordinate the claims review process.


The incumbent has the authority to make decisions regarding medical issues based on any edits or CodeReview guidelines established for the review of claims. This position requires that these decisions be based on sound judgment and complete understanding of the relationship of contractual limitations and standard/nonstandard care. The incumbent must understand and be able to apply medical necessity and pricing criteria. The incumbent is involved in researching specific claims issues and must identify those issues which may affect future claims review. This position also has the authority to recommend to management solutions to problems that may arise during claims review or project resolution. The incumbent is also responsible for assisting in the development and updating of prepayment edits and guidelines.


This position requires excellent oral and written skills; the ability to make sound judgments and decisions based on facts and guidelines; and the ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency. The incumbent demonstrates an ability to train and educate others on the current claims review processes.

Minimum Job Requirements

1. Registered nurse license in the state of Arkansas.
2. Experience in nursing as an RN, to include a broad background in various facets of nursing.
3. Utilization management experience or background in medical economics preferred.
4. Surgical or critical care nursing background preferred.
5. Typing or data entry skills.

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

1. Conduct prepayment review or all inpatient/outpatient hospital, physician, and supplier claims for Blue Advantage National Accounts product line.
2. Attain performance standards as established in the business plan for the division.
3. Assist in the research and development of special projects involving specific providers, pricing or contractual issues, medical necessity or medical policy issues, and work flow issues.
4. Assist in edit maintenance by identifying problems within the edits, proactively identifying provider and/or subscriber abuse, and being alert to ongoing changes in billing and medical practice.
5. Participate in the development and updating of desk procedures and guidelines.
6. Ensure that claims are adjudicated according to accepted standards of medical practice and based on Corporate Medical Policy, CodeReview logic, contractual guidelines, and regulatory requirements.
7. Maintain and update knowledge of new medical and surgical procedures and products, new drugs, and general trends in health care delivery.
8. Consult with other teams within the Medical Audit & Review Division, Customer Service and Claims Processing areas for Blue Advantage National Accounts product line, Corporate Medical Director, Regional Offices, and others within the Enterprise.
9. Initiate correspondence to physician, suppliers and hospitals requesting additional information on questionable claims.
11. Perform system research on specific claims issues either by consulting with the UR Researcher or Medical Audit & Review Support Specialist or by accessing the processing system and performing research.
12. Collect data and report claims activity monthly and maintain accurate daily and weekly figures on claims movement within the prepayment medical review section.
13. Assist in the ongoing development and updating of pricing criteria.
15. Works collaboratively with other teams within the division.
16. Participates in on-going evaluation of himself/herself and of the nursing team.
17.Assists in the development of plans for process improvement.
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