Grade 6

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.

Roles and 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

• Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically Medicare and medical necessity review.

• Uses sound judgment, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards

• Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals.

• Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.

• Prepare case recommendations for medical review as necessary.

Requirements:

• 3 – 5 years of experience in processing appeals or utilization management

• RN – Registered Nurse – State required Licensure and/or Compact State Licensure

• Knowledge of utilization management processes

• Knowledge of NCQA, Medicare and Medicaid regulations

• Good communication (Demonstrate strong reading comprehension and writing skills)

• Able to work independently, strong analytic skills

Required shift timings:

US daytime