Responsible for preparing cases for physician review and all appeal related activities accurately, efficiently, and within mandated timeline requirements. Performs appeal reviews on medical and/or behavioral health records and cases utilizing established guidelines and member benefit plans. Communicates the outcome of the appeals process with members, internal and external partners.
Department: Health Services
Reports to: Mgr, Appeals
Location: Tampa, FL 33634
- 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 and/or denial letters on behalf of the Medical Director for submission to member, provider or hospital.
- Ensures 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.
- Performs special duties as assigned.
Licenses and Certifications:
- A license in one of the following is required:
- LPN, RN, LSW, LMHC, or LCSW
Candidate Minimum Education:
- Required A High School or GED
- Required: 2 years of experience in a clinical setting with general nursing exposure in utilization management (UM), to include pre-authorization, utilization review, concurrent review, discharge planning, case management with review, and/or skilled nursing facility reviews.
- Preferred: 2 years of experience in an acute care clinical setting (medical and/or behavioral health)
- Preferred: 2 years of experience in managed care
- Advanced ability to create, review and interpret treatment plans
- Advanced ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Advanced knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
- Intermediate proficiency in a healthcare management system
- Ability to use a proprietary healthcare management system