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Capital Blue Cross
A & G Resolution Nurse
Remote · United States · Full time · Mid level
About the role
Provide resolution of complex clinical complaints, grievances, and appeals. Review clinical records and coordinate clinical resolutions with internal and external clinicians.
What you’ll do
• Provide complex clinical support for complaints, grievances, and appeals. • Review and analyze clinical issues and recommend policy updates. • Coordinate legal recommendations and department liaison duties. • Serve as clinical reference for Plan personnel. • Provide on-call weekend and holiday coverage on rotation.
What you’ll bring
• Minimum 5 years clinical experience including Medicare C and D knowledge. • Bachelor’s degree required. • RN Certification required. • Knowledge of URAC, NCQA, CMSA standards. • Proficient with Microsoft Office and clinical databases.
Life at Capital Blue Cross
Flexible environment prioritizing health and wellbeing. Supportive team culture with community volunteering encouraged. Investment in training and continuing education.
About Capital Blue Cross
Capital Blue Cross is committed to improving health and well-being of members and communities, fostering a caring and flexible workplace.