Clinical Appeals Coordinator, RN - Peak Health

WVU Medicine

94d

About The Position

Design and build a health plan from the ground up as an Clinical Appeals Coordinator. Reporting to the Health Plan Manager of Utilization Review, the Appeals Nurse, will be an integral member of the health plan’s medical management team. The Appeals Nurse will investigate and process medical necessity requests from both members and providers. The Clinical Appeals Coordinator is a collaborative member of the Medical Management team.

Requirements

• Bachelor of Science in Nursing from accredited nursing program.
• Must maintain an active and non-restricted license in the State of West Virginia or reside outside of State and hold a compact license.
• Five (5) years of clinical experience, with two years of experience in a related field of case management or utilization review.

Nice To Haves

• Medical Management experience preferred.

Responsibilities

• Conducts and leads investigations and reviews for member and provider medical necessity appeals.
• Reviews the medical record of denied services for medical necessity.
• For prospective reviews, reviews relevant clinical notations leading up to the request for services.
• Provides a summary of case for the medical director, and other partners in the health plan care team.
• Ensures that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements.
• Documents and logs case information for the appeal.
• Generates the written response to the member or provider.
• Serves as a subject matter expert for appeals and grievances.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees