Job Description

Clinical Appeals Specialist

The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial lines of business in order to formulate a professional response to the appeal request.

Essential Functions:

• Investigate, interpret, and analyze written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
• Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights.
• Investigate, interpret, analyze and prioritize appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accreditation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS.
• Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

Qualifications:

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Education Level: High School Diploma
• Education Details:
• Experience: 2 years medical-surgical or similar clinical experience OR 3 years' experience in mental health, psychiatric setting.

Preferred Qualifications:

• 2 years' experience in Medical Review, Utilization Management or Case Management at Client, or similar Managed Care organization or hospital preferred.
• BSN/MSN Degree

Knowledge, Skills and Abilities (KSAs):

• Knowledge and understanding of medical terminology.
• Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task.
• Ability to effectively communicate and provide positive customer service to every internal and external customer.
• Knowledge of Microsoft Office programs.
• Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req
• CCM - Certified Case Manager Upon Hire Pref
• LNCC - Legal Nurse Consultant Certified Upon Hire Pref

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