Note: The job is a remote job and is open to candidates in USA. Peak Health is building a health plan and seeking a Clinical Appeals Coordinator to join its medical management team. The role investigates and processes medical necessity appeals from members and providers, reviews clinical records, prepares case summaries and written responses, and ensures compliance with applicable appeal timeframes and regulatory standards.
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
Skills
- 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)
- 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
- Bachelor of Science in Nursing
- Medical Management experience
Company Overview