Clinical Appeals Coordinator

WVU Medicine • Home Work - Monongalia County WV (Local), WV

2d • Onsite

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

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). OR Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC) AND Three (3) years of clinical experience.
• Three (3) years’ experience with clinical claims processing and review.
• Three (3) years’ experience working with appeal and grievances.
• Two (2) years’ customer service experience.
• Working Knowledge of InterQual and/or Milliman Care Guidelines
• Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning
• Excellent written and oral communication
• Problem solving capabilities to drive improved efficiencies and customer satisfaction
• Attention to detail
• Proficiency with Microsoft Office

Nice To Haves

• Bachelor of Science in Nursing.
• Medical Management experience.

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.
• Commit 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
• Career Level: Mid Level