ROLE: 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 and Government Programs lines of business in order to formulate a professional response to the appeal request.
Essential Functions
35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders 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.
35% 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.
25% Investigates, interprets, analyzes and prioritizes 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 accredidation 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.
5% 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.
Knowledge, Skills And Abilities (KSAs)
Knowledge and understanding of medical terminology., Advanced
Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient
Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task , Proficient
Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced
Knowledge of Microsoft Office programs., Proficient
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., Proficient
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
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
Mandatory Skills
Previous clinical review nursing experience
Ability to research and analyze clinical records
Ability to prioritize work day to maintain timeliness
Ability to review multiple platforms to determine needs
Ability to contact provider offices and determine needs for member's appeals
- Talteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.**
