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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.
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.
Additional Responsibilities:Candidate Education:
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
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
Licenses and Certifications: 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