Clinical Appeals Coordinator

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MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). 

OR

2. Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC) AND Three (3) years of clinical experience.

EXPERIENCE:

1. Three (3) years’ experience with clinical claims processing and review.

2. Three (3) years’ experience working with appeal and grievances.

3. Two (2) years’ customer service experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing.

EXPERIENCE:

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Conducts and leads investigations and reviews for member and provider medical necessity appeals.

2. Reviews the medical record of denied services for medical necessity.  For prospective reviews, reviews relevant clinical notations leading up to the request for services.

3. Provides a summary of case for the medical director, and other partners in the health plan care team.

4. Ensures that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements.

5. Documents and logs case information for the appeal.

6. Generates the written response to the member or provider.

7. Serves as a subject matter expert for appeals and grievances.

8. Commit to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning

3. Excellent written and oral communication

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction

5. Attention to detail

6. Proficiency with Microsoft Office

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: