Behavioral Health Appeals Coordinator Sr

Elevance Health•Walnut Creek, CA

5d•Remote

About The Position

The Behavioral Health Appeals Coordinator Senior is responsible for investigating and processing the most complex grievances and appeals requests from members and providers related to behavioral health services. Serves as a technical resource to team and may be assigned to work on projects in support of medical policy and/or managed care initiatives.

Requirements

Requires MS in social work, RN or degree in a related behavioral health field and minimum of 4 years of experience in a managed care/healthcare setting; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor or RN license to practice as a health care professional within scope of licensure in applicable state(s) or territory of the United States required.

Nice To Haves

Current active, unrestricted license as an LCSW, LMFT, Clinical Psychologist, LPC, or RN , issued in the State of California (CA) authorized to practice within scope of licensure strongly preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Investigates and reviews member and provider grievances and appeals.
Generally works on issues that are of a complex nature.
Serves as an internal resource for lower level behavioral health appeal coordinators and staff.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to medical director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs information on tracking systems and mainframe systems.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Participates in projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.