Behavioral Health Clinical Appeals Reviewer

Health Care Service Corporation; Chicago (IL); Remote; USD 60,000 - 134,000; Full time

Job summary

Join a purpose-driven organization that values employee growth and offers a fulfilling career in Behavioral Health. This remote role involves coordinating clinical appeals and grievances, ensuring compliance with regulatory standards, and engaging with various stakeholders. Ideal candidates will possess strong clinical experience, excellent communication skills, and a passion for making a difference in the healthcare landscape. Enjoy the flexibility of remote work while contributing to a team dedicated to enhancing patient care and outcomes. If you're ready to take your career to the next level in a supportive environment, this opportunity is for you.

Qualifications

• Must be a licensed RN or Masters-level Behavioral Health Professional.
• 4 years of clinical experience required post-licensure.

Responsibilities

• Coordinate clinical appeals/grievances for Behavioral Health.
• Analyze appeals data and prepare cases for review.

Skills

Clinical experience

Communication skills

Interpersonal skills

Organizational skills

Detail oriented

Bilingual (English and Spanish)

Education

Registered Nurse (RN)

Masters-level Behavioral Health Professional

Tools

Microsoft Excel

Data Analytics

Electronic Records

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

This position is responsible for coordinating clinical appeals/grievances and complaints for Behavioral Health, reporting, monitoring, scheduling and facilitating appeals according to various regulatory requirements. Analyzes appeals data, determines appeals decisions or prepares cases for Medical Director review.

Job Requirements:

1. Registered Nurse (RN) or Masters-level Behavioral Health Professional (LPC, LMFT, LCSW, LCPC) with current license to practice at the independent practice level.
2. 4 years clinical experience (post licensure at the independent practice level) to include implementing or administering managed care or quality assurance activities.
3. Knowledge and understanding of state and federal guidelines and regulations.
4. Written and verbal communication skills and facilitating skills.
5. Interpersonal skills to interface with internal and external customers, including representatives of Department of Insurance and government agencies in a rapport-developing manner.
6. Organizational skills.
7. Detail oriented.

Preferred Job Requirements:

1. Bilingual in English and Spanish.
2. Experience in processing appeals, denials or grievances in accordance with regulatory or accreditation requirements.
3. Experience in Utilization Management or audit.

#LI-Remote

This is a Telecommute (Remote) role for TX, OK, NM, MT and IL: Must reside anywhere within the posted State(s).

** Masters-level Behavioral Health Professionals: Please note that you MUST be licensed to practice at the independent level for this role. The # of years of clinical experience required for this role is post licensure (# of years) at the independent level**

*Strong Utilization Review (UR) experience needed.

*Knowledge of Excel (Microsoft Suite) is needed, as well as experience with Claims, Data Analytics, and Electronic Records is preferred.

Work Schedule: Work Hours are Monday through Friday 8:30 AM to 5:30 PM (Time Zone aligned).

Sponsorship is not available.

The Compensation/Salary offered for this Position will vary depending on job-related skills, education, knowledge and experience. This role aligns with an Annual Performance Incentive (Bonus) plan.

We encourage people of all backgrounds and experiences to apply.

Compensation: $60,300.00 - $133,400.00

Exact compensation may vary based on skills, experience, and location.

HCSC Employment Statement:

We are an Equal Opportunity Employment / Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

To learn more about available benefits, please click https://careers.hcsc.com/totalrewards