Appeals RN Utilization Review

General Summary of Position
Responsible for the facilitation and management of medical appeals and may assist with clinically oriented claims issues. Investigates and resolves member and practitioner appeals within plan regulatory and accreditation timeframes. Performs ER review activities.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Abstracts medical record analyzes clinical information and Approves payment of services in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
• Conducts an initial medical record review for all clinical appeals including inpatient and outpatient and prepare a summary of the case outlining the issue(s) for the Medical Director's review. Appeals Nurse prepares a draft response to the appeal for review by the Medical Director in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
• Conducts an initial review of appeals of emergency room administrative denials against Prudent Layperson Criteria medical necessity appropriateness of coding and health plan policies. Appeals Nurse overturns administrative denials and approves payment when standards are met.
• Conducts an initial review of appeals of emergency room non-administrative denials against Prudent Layperson Criteria medical necessity appropriateness of coding and health plan policies. Appeals Nurse makes a recommendation to uphold or overturn the denial and prepares a draft response for review by the Medical Director in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
• Coordinates closely with Medical Directors on handling denials adverse determinations or clinically oriented grievances.
• Documents all appeals in an accurate and timely manner per policy related follow-up activities and final outcomes in clinical software system while concurrently maintaining secure comprehensive and clearly defined files.
• Documents ER review activity in the clinical software system.
• Documents in the clinical software system as appropriate. Reviews each appeal received to determine whether the case is a medical appeal or a claim/administrative appeal.
• Forwards recommendation to Deny services to Medical Director. Appeals Nurse will prepare draft of denial reason for MD review in accordance with NCQA Maryland COMAR the District of Columbia contract and MedStar Family Choice Policies/Procedures.
• Participates in inter rater reviews and associated meetings/activities.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
• Participates in the processing of ER records for appropriateness of service.
• Performs other duties as assigned.
• Performs primary preparation of ER Claims in the clinical software system to administratively deny claims without attached medical records and duplicate submissions.
• Works collaboratively with the Appeals staff Administrative staff and Medical Directors.

Minimal Qualifications
Education

• Bachelor's degree in Nursing required

Experience

• 5-7 years Diverse clinical experience; experience applying industry standard criteria to clinical information for example interqual. knowledge of common and standard authorization processes. required and
• 1-2 years 2 years of recent utilization review experience. required and
• Prior experience in appeals preferred

Licenses and Certifications

• Active and Unrestricted Nursing License in the State of Maryland required or
• he District of Columbia with a willingness to obtain license in both jurisdictions. required or
• No prior current or pending Medicare or Medicaid sanctions. required and
• No RN license sanctions. required

Knowledge Skills and Abilities

• Ability to read and interpret medical records.
• Ability to abstract analyze and summarize medical/clinical situations.
• Excellent verbal and written communication skills.
• Ability to work independently.
• Ability to prioritize and organize work to meet deadlines.
• Knowledge of medical claims and coding desirable.
• Ability to work effectively in teams.
• Computer/Keyboarding skills and familiarity with Microsoft Office or similar software.
• Maintain current knowledge of MFC policies and procedures and participate in continuing education activities as appropriate.