Performs clinical reviews needed to resolve and process appeals by reviewing 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:
Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
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.
Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
Prepare case recommendations for medical review as necessary.
1-3 years of experience in processing appeals or utilization management.
RN - Registered Nurse - State required Licensure and/or Compact State Licensure
Knowledge of utilization management process
Knowledge of NCQA, Medicaid regulations
Good communication (Demonstrate strong reading comprehension and writing skills)
Able to work independently, strong analytic skills
Required shift timings - US daytime
...Lets be #BrilliantTogether Overview ISS STOXX is hiring! We are looking for a Junior UI/UX Designer to accelerate our transformation and deliver a persona-based approach in a modern interface to our customers. This role will sit within the product organization...
...Title: Data Engineer Location: Plano, TX Duration: 6 Months Data Engineer with strong expertise in data modeling, data warehousing, and cloud-based data platforms. The ideal candidate will have hands-on experience with AWS data services, SQL-based data...
...Additional Information AS A MEMBER OF THE EQUINOX TEAM YOU WILL RECEIVE: We offer competitive salary, benefits, and industry leading commission opportunities for club employees Complimentary Club membership Perks and incentives with our products and...
...Part-Time Construction Safety Manager (OSHA 30 Required) Commercial Construction | $35$38/hr We are hiring an experienced Construction Safety Manager to lead safety programs across active commercial construction sites. This part-time, in-person role is ideal...
...Position: Virtual Assistant I Location: Remote, United States Company Overview: Brandcoven is a leading digital marketing agency that specializes in helping businesses grow their online presence. Our team is made up of talented individuals who are passionate...