Job Profile Summary
Position Purpose:
Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required or
LVN - Licensed Vocational Nurse required or
RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
LCSW- License Clinical Social Worker required or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Marital and Family Therapist (LMFT) required or
Licensed Psychologist required
For Health Net of California: RN license required
Responsibilities
Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Job Profile Summary
Position Purpose:
Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required or
LVN - Licensed Vocational Nurse required or
RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
LCSW- License Clinical Social Worker required or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Marital and Family Therapist (LMFT) required or
Licensed Psychologist required
For Health Net of California: RN license required
Responsibilities
Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned
Complies with all policies and standards
Story Behind the Need – Business Group & Key Projects - Health plan or business unit
- Team culture
- Surrounding team & key projects
- Purpose of this team
- Reason for the request
- Motivators for this need
- Any additional upcoming hiring needs?
Shared Services Medicare Appeals department located within EBOS. We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. These reviews determine if members can/did receive medically necessary services.
Department is launching a BPO with expected team impacts. Resignations have come in and the need for this request is to mitigate staff leaving until BPO is up and running.
Typical Day in the Role - Daily schedule & OT expectations
- Typical task breakdown and rhythm
- Interaction level with team
- Work environment description
Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on. Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations. Work closely with the MD team to make final decisions on cases. The clinical team works closely with their supervisors and senior clinicians on the team for support. Team does have group chats on Teams for routine questions. Team works closely together along with the coordinator team who owns end to end process on cases.
Compelling Story & Candidate Value Proposition - What makes this role interesting?
- Points about team culture
- Competitive market comparison
- Unique selling points
- Value added or experience gained
Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.
Candidate Requirements Education/Certification Required Preferred: :
Associate in nursing, Bachelor’s in nursing or higher. Licensure Required:
RN, LPN Preferred: LVN
- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals
Nice to haves: Medicare Appeals Experience
Disqualifiers: Not having a valid/active RN/LPN license
Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases
Best vs. average: Productivity expectations are set based on platform.
- Top 3 must-have hard skills
- Level of experience with each
- Stack-ranked by importance
- Candidate Review & Selection
1 Utilization Management or Appeals review background (1 plus year) 2 Medicare NCD/LCD and InterQual/Milliman Software (1 plus year) 3 Retrospective claims clinical reviews (1 plus year)
Candidate Review & Selection - Shortlisting process
- Second touchpoint for feedback
- Interview Information
- Onboard Process and Expectations
Projected HM Candidate Review Date: 2 business days Number and Type of Interviews: On camera (1) Extra Interview Prep for Candidate: N/A Required Testing or Assessment (by Vendor): N/A
Manager Communication Preferences & Next Steps - Background Check Requirements (List DFPS or other specialty checks here)
Clinical Licensure requirements
- Do you have any upcoming PTO?
No
- Colleagues to cc/delegate
Sarah Goodwin 
