Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals to team members.
- Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
Roles and Responsibilities:
- Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
- Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
- Ensures timely review, accurate processing, and response to appeal in accordance with State, Federal and NCQA standards.
- May also perform clinical reviews. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
- Communicates with providers, facilities and other departments regarding appeal requests.
- Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards.
- Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests.
- Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
- Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review.
- Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards.
- Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals.
- 1-3 years of experience in processing appeals or utilization management.
- 1 yr experience in advanced roles such as team lead, trainer, SME, or QA
- RN - Registered Nurse - State required Licensure and/or Compact State Licensure
- Knowledge of utilization management process
- Knowledge of NCQA, Medicaid requlations
- Good communication (Demonstrate strong reading comprehension and writing skills)
- Able to work independently, strong analytic skills
- Required shift timings - US daytime