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Capital Blue CrossPosted 10/21/2026full-timeRemote • Pennsylvania • United StatesMid-LevelSenior💰 $29 - $54 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in resolving complex clinical complaints and grievances while ensuring compliance with regulatory standards. Proficient in analyzing clinical data and providing support for clinical projects and case management.
Highest-signal resume keywords
RN Certification5 Years Clinical ExperienceKnowledge Of Medicare C And DKnowledge Of URAC And NCQA StandardsProficiency In Microsoft Office Suite
About the role
Key responsibilities & impact- Resolve complex clinical complaints, grievances, and appeals
- Review documentation and interpret clinical-record data using clinical criteria and policies
- Ensure compliance with regulatory and accreditation requirements for member and provider issues
- Coordinate clinical resolution with internal and external clinician support
- Document and summarize case results for involved parties
- Provide complex clinical support for corporate, department, and special projects
- Draft recommendations and communicate solutions concerning Complaints, Grievances, and Appeals
- Identify, review, and analyze complex clinical issues involving corporate policies, procedures, and contracts
- Consult with Management, Government Programs, group leaders, and other external contacts
- Recommend improvements, updates, and clarifications to policies and procedures
- Follow up on policy and procedure changes and initiate revisions to supporting documentation
- Liaise with departments on cases requiring legal recommendations and direction
- Serve as a clinical reference for Plan personnel regarding inquiries and applicable guidelines
- Conduct peer reviews and document findings as assigned
- Provide audit support, desk mentoring, and functional training for peers
- Provide rotating on-call weekend and holiday coverage
Requirements
What you’ll need- Bachelor’s degree is required
- RN Certification is required
- Minimum of 5 years clinical experience
- Working knowledge of Medicare C and D
- Knowledge of URAC and NCQA standards for case management organizations
- Knowledge of CMSA Standards of Practice for Complaints, Appeals, and Grievances
- Knowledge of managed care principles and emerging health treatment modalities
- Proficiency in Microsoft Word, Access, Excel, Outlook, and clinical databases
- Ability to use a personal computer and talk-and-type documentation
- Analytical, research, and organizational skills
- Verbal and written communication skills
- Project management skills and ability to manage multiple assignments
- Ability to work independently and adjust to changing priorities
- Ability to provide rotating on-call weekend and holiday coverage
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Retirement Plan
- Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
- Flexible work environment
- Training and continuing education
- Professional and personal growth opportunities
- Community volunteering opportunities
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Data InterpretationCase ManagementPolicy ComplianceClinical DocumentationAnalytical SkillsProject ManagementPeer ReviewClinical SupportGrievance ResolutionResearch Skills
Soft Skills
Verbal CommunicationWritten CommunicationOrganizational SkillsAbility To Work IndependentlyAdaptability
Tools & Technologies
Microsoft WordMicrosoft AccessMicrosoft ExcelMicrosoft OutlookClinical Databases
Certifications & Qualifications
Bachelor's DegreeRN Certification
Industry Keywords
Managed Care PrinciplesCMSA Standards Of PracticeClinical ComplaintsGrievancesAppealsRegulatory ComplianceAccreditation RequirementsClinical ReferenceLegal RecommendationsDesk Mentoring