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: 3000 - HS - Appeals & Grievances
Manager Title: Supv. Clinical Appeals
Additional Responsibilities:Candidate Education:
- 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.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 2 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.
- Preferred 1 year of experience in an acute care clinical setting (Medical and/or Behavioral Health)
- Preferred 2 years of experience in Managed care experience
Licenses and Certifications:
- 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
A license in one of the following is required:
- Required Other Requires one of the following: LPN, RN, LSW, LMHC, LCSW
- Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word, Excel, Power Point and Outlook
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Required Beginner Microsoft PowerPoint
- Required Intermediate Healthcare Management Systems (Generic) Ability to use proprietary healthcare management system