Über
Conducts investigations and reviews of member and provider medical necessity appeals. 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 appeal/grievance information on relevant tracking systems and mainframe systems. Generates written correspondence to providers, members, and regulatory entities. Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
Minimum requirements:
Requires a HS diploma or equivalent and a minimum of 2 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 RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Preferred Skills, Capabilities and Experiences:
AS or BS in Nursing preferred. Three to five years of clinical experience as a Registered Nurse strongly preferred. Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred. Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred. Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred. Experience with Facets, Macess, and ACMP is preferred.
Job Level: Non-Management Exempt Workshift: Job Family: MED > Licensed Nurse
Sprachkenntnisse
- English
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