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.

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

Worker Type:

Employee

Company:

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.