Clinical Appeals Coordinator

Peak Health; Core (WV); On-site; USD 60,000 - 85,000; Full time

Job summary

PHH Peak Health Holdings in the United States seeks a Clinical Appeals Coordinator (RN or LPN) to help design and build a health plan from the ground up. Reporting to the Health Plan Manager of Utilization Review, you will investigate and process medical necessity requests from members and providers as part of the medical management team.

You will lead investigations, review denied services, log cases, and generate written responses.

Qualifications

• RN or LPN license required or multi-state license via eNLC
• Three (3) years of clinical claims processing and review experience
• Three (3) years of appeals and grievances experience
• Two (2) years of customer service experience
• BSN preferred

Responsibilities

• Conducts and leads investigations and reviews for member and provider medical necessity appeals.
• Reviews the medical records of denied services for medical necessity; for prospective reviews, reviews relevant clinical notations leading up to the request.
• Provides a summary of case for the medical director and care team.
• Ensures appeal timeframes meet enterprise, state, and federal standards.
• Documents and logs case information for the appeal; generates written responses.
• Serves as a subject matter expert for appeals and grievances.

Skills

InterQual

Milliman Care Guidelines

Federal and state laws knowledge

Excellent written and oral沟通

Problem solving

Attention to detail

Education

RN license

LPN license

Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

Welcome! We’re excited you’re considering an opportunity with us! Below, you’ll find other important information about this position.

Design and build a health plan from the ground up as an Clinical Appeals Coordinator. Reporting to the Health Plan Manager of Utilization Review, the Appeals Nurse, will be an integral member of the health plan’s medical management team. The Appeals Nurse will investigate and process medical necessity requests from both members and providers.

The Clinical Appeals Coordinator is a collaborative member of the Medical Management team.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• 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).

OR

• 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.

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.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Bachelor of Science in Nursing.

EXPERIENCE:

• Medical Management experience.

CORE DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• 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.

PHYSICAL REQUIREMENTS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Standard office environment

SKILLS AND ABILITIES:

• 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

Additional Job Description:

Scheduled Weekly Hours:

40

Exempt/Non-Exempt:

Shift:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

529 PHH Clinical Integration