[Remote] Clinical Appeals Coordinator

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is building a health plan and seeking a Clinical Appeals Coordinator to join its medical management team. The role investigates and processes medical necessity appeals from members and providers, reviews clinical records, prepares case summaries and written responses, and ensures compliance with applicable appeal timeframes and regulatory standards.

Responsibilities

• 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 reputed company 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 reputed company, 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
• reputed company to a career of life-long learning and reputed company improvement of processes that reputed company the reputed company of Utilization Review

Skills

• reputed company Registered reputed company license issued by the state in which services will be provided or reputed company multi-state Registered reputed company license through the reputed company reputed company Licensure Compact (eNLC)
• reputed company Licensed Practical reputed company license issued by the state in which services will be provided or reputed company multi-state Licensed Practical reputed company license through the reputed company reputed company Licensure Compact (eNLC) AND Three (3) years of clinical 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
• Working Knowledge of InterQual and/or reputed company Care Guidelines
• Demonstrated knowledge of federal and state laws, reputed company and industry regulations reputed company to disease management, utilization management, case management and discharge planning
• Excellent written and oral communication
• Problem solving capabilities to reputed company improved efficiencies and customer satisfaction
• Attention to detail
• Proficiency with reputed company Office
• Bachelor of Science in Nursing
• Medical Management experience

reputed company