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:

• 2 – 4 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