Clinical Appeals Reviewer, Sr

Department: Health Services - Appeals & Grievance

Reports to: Sr. Manager, Appeals

Location: 4888 Loop Central Drive, Houston TX 77081

Job Type: Hourly/ Non-Exempt

Reviews clinical information provided by the facility and providers to evaluate the medical necessity and clinical appropriateness of requested services for a member. Uses clinical expertise and compares information from established guidelines and member benefit plans against medical records and notes. Works closely with the departmental management to impact the established set of goals and identify opportunities for improvement in workflows, training, and implementation to resolve problems. Provides training to new Appeals Reviewers.

Essential Functions:

  • Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with appeal determinations.
  • Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action towards appeal.
  • Applies regulatory requirements and accreditation standards to all review activity and reporting.
  • Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems.
  • Prepares and submit projects, reports or assignments as needed to meet department initiatives and/or objectives.
  • Produces approval & denial letters on behalf of the Medical Director for submission to member, provider or hospital.
  • Ensure quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing.
  • Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies.
  • Creates training materials and acts as a team trainer on new and revised policies and criteria.
  • Acts as a subject matter expert (SME) within the department. Handles escalated issues from Concurrent Review Nurses.
  • Performs department and clinical audits at the request of management.
  • Performs special duties as assigned.

Candidate Education:

  • Required A High School or GED
  • Preferred A Bachelor's Degree in a related area
Candidate Experience:
  • Required 4 years of experience in a clinical setting with general nursing exposure in UM to include pre-authorization, utilization review, concurrent review, discharge planning, CM w/review, and/or skilled nursing facility reviews. 4 years to include 1 year of acute care experience.
  • Required 1 year of experience in an acute care setting (Medical)
  • Preferred 4 years of experience in managed care
Candidate Skills:
  • Intermediate Ability to create, review and interpret treatment plans
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Intermediate Knowledge of community, state and federal laws and resources
  • Intermediate Other Ability to review multiple type of appeal files (member/provider, retro/pre-service, etc).
  • Intermediate Other Ability to build high morale and obtain group commitments to goals and objectives.
  • Intermediate Other Capability of working extra time and/or be “on-call” at request of management.
  • Intermediate Other IRR Appeals Reviewer Test - >85% passing score.
  • Intermediate Other Ability to consistently meet the established production goals (over 30 files/week)
Licenses and Certifications:
A license in one of the following is required:
  • Required Licensed Practical Nurse (LPN)
  • Requires one of the following: LPN, RN, LSW, LMHC, LCSW
Technical Skills:
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft PowerPoint
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Healthcare Management Systems (Generic) Ability to use proprietary healthcare management system

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.