"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 analyzing 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-rooutine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards.
Maintain files on individual appeals by gathering, analyzing 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 recommemdations 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 requlations
Good communication (Demonstrate strong reading comprehension and writing skills)
Able to work independently, strong analytic skills
Required shift timings - US daytime"
...years of technician experience, and some of their own tools. Schedule:5 day work week - Closed Weekends! Benefits: ~ Health and Dental Insurance ~ Paid Time Off ~ Paid Life Insurance ~401(k) We Provide: A nice, clean and safe facility Career growth...
*Special Education Teacher - Hubbard Day - *_Stamford, CT_ Hubbard Day, a 1:1 special education school in Stamford, CT is looking to bring a special education teacher to our newly built out 20,000 square foot waterfront campus. We are a rapidly growing full day alternative...
Overview: This a PRN position working on an as needed basis. Responsibilities:Responsible for providing a variety of patient... ...Education Degree (GED) Required Graduation from an accredited Medical Assistant program accredited through the Commission on Accreditation of...
...DBS Staffing Services, Inc. is currently seeking dedicated individuals for Post Construction Cleaning positions. As a family-owned staffing company, we aim to connect quality candidates with reputable clients. In this role, you will play a vital part in ensuring that newly...
...The University of Maryland Medical System (UMMS) is an academic private health system, focused on delivering compassionate, high... ...Job Summary Under direct supervision of the on-site provider, assists in the delivery of patient care. Performs delegated medical tasks...