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Health Services WellCare - Nursing Careers

Clinical Appeals Reviewer Job

Full Job Title: Clinical Appeals Reviewer

Job Number: 1802149

Location: Tampa, FL

Date Posted: 2018-06-13

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.

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 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
    Candidate Experience:
    • 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
    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
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Other Requires one of the following: LPN, RN, LSW, LMHC, LCSW
    Technical Skills:
    • 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

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      Last Updated On: 12/9/2015