[Hiring] Clinical Appeals Coordinator @WVU Medicine

Role Description

Design and build a health plan from the ground up as a Clinical Appeals Coordinator. Reporting to the Health Plan Manager of Utilization Review, the Appeals Nurse will be an integral member of the health plan’s medical management team. The Appeals Nurse will investigate and process medical necessity requests from both members and providers.

The Clinical Appeals Coordinator is a collaborative member of the Medical Management team.

Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• OR Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse 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 appeals and grievances.
• Two (2) years’ customer service experience.

Requirements

• Bachelor of Science in Nursing (preferred).
• Medical Management experience (preferred).

Core Duties and Responsibilities

• Conducts and leads investigations and reviews for member and provider medical necessity appeals.
• Reviews the medical record of denied services for medical necessity.
• Provides a summary 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 enterprise, 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.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

• Standard office environment.

Skills and Abilities

• Working knowledge of InterQual and/or Milliman Care Guidelines.
• Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management, and discharge planning.
• Excellent written and oral communication.
• Problem-solving capabilities to drive improved efficiencies and customer satisfaction.
• Attention to detail.
• Proficiency with Microsoft Office.

Additional Job Information

• Scheduled Weekly Hours: 40
• Shift: Exempt/Non-Exempt
• United States of America (Exempt)
• Company: PHH Peak Health Holdings
• Cost Center: 529 PHH Clinical Integration