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Health Services WellCare - Nursing Careers

Clinical Appeals Reviewer Job

Full Job Title: *Clinical Appeals Reviewer

Job Number: 1806107

Location: Tampa, FL

Date Posted: 2018-08-18

Department: Health Services -Appeals & Grievances

Reports to: Clinical Appeals Supervisor

Location: 8715 Henderson Rd, Tampa, FL 33634

Job Type: Hourly / Non-exempt

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.

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