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 analysing 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, analysing 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
...Description We are looking for a reliable and detail-driven Bookkeeper to manage our financial records and day-to-day accounting... ...and principles Proficiency with accounting software (e.g., QuickBooks, Xero, Wave) Strong attention to detail and organizational skills...
...A hospital-owned, multi-specialty group with over 80 providers that covers 4 counties, is hiring an experienced Neurology Physician Assistant to join its busy, outpatient practice on the coast of North Carolina. Practice Details Clinical hours are Monday-Friday...
...POSITION: This classification specification describes the entry-level of the Forensic Behavioral Health Clinician classification flexibly-... ...management and the operation of standard office equipment. Computer applications related to the work. Ability to: Work...
...AFL-CIO Director of Data and Technology Data, Analytics, and Infrastructure Resource... ...campaigns. This position reports to the Chief of Staff. The American Federation of... ...and polling and research to the officers and executive offices. Work closely with...
...beauty and lifestyle brands under our belt. We aim to be the ultimate K-Beauty destination. We seek a dedicated & passionate Event Promoter , a character that is responsible, diligent and self-motivated. The Event Promoter will be responsible for maintaining high...