[Hiring] Appeals Clinical Consultant @Point32Health

Role Description

Under the direction of the Director, Appeals & Grievances, the Clinical Consultant – Appeals & Grievances (A&G) will perform a variety of roles that focus on clinical support of department staff as well as develop effective working relationships with internal partner departments and vendors utilized by the Appeals & Grievances Department. The Clinical Consultant – A&G will be the liaison for all clinical issues involved in the Appeals & Grievances work. This role will assist with support and providing responses to escalate member and provider issues.

The position requires a highly motivated individual with an understanding of Appeals & Grievances processes, particularly in the managed care environment with a focus on Commercial plans and Medicaid. Critical to the success of this role is the ability to demonstrate strength working independently as well as collaboratively within the team environment.

• Serves as key clinical resource for various aspects of Appeal & Grievances work
• Provide support to Analyst team in developing knowledge and understanding of medical terminology and provider plan of care relative to appeal
• Utilize clinical knowledge to analyze, assess, and consult with Analyst to determine the need for various aspects of physician review
• Identifies complex members and collaborate with Analyst to refer members to case management or disease management program based on member specific diagnoses, circumstances or psycho social needs, and product / LOB program requirements, with the goal of improving individual member satisfaction
• Assess drivers of appeals and grievance trends and work with A&G leadership in developing messaging to internal stakeholders (SLT, Product Team, Stars Team etc.)
• Consults with Analyst and MD reviewers on complex appeals and grievances
• Assist Analyst with case preparation and participate as a voting member in cross-functional Appeals Committees providing clinical input within scope of practice for appeal decisions
• Assist department trainer with new hire training as it relates to clinical aspects of A&G work
• Other duties and projects as assigned

Qualifications

• Understanding of Appeals & Grievances processes
• Experience in managed care environment, particularly with Commercial plans and Medicaid
• Ability to work independently and collaboratively

Requirements

• Strong clinical knowledge
• Ability to analyze and assess clinical situations
• Effective communication skills

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health