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Reviews clinical information provided by the facility and providers to evaluate the medical necessity and clinical appropriateness of requested services for a member. Uses clinical expertise and compares information from established guidelines and member benefit plans against medical records and notes. Works closely with the departmental management to impact the established set of goals and identify opportunities for improvement in workflows, training, and implementation to resolve problems. Provides training to new Appeals Reviewers.
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 & denial letters on behalf of the Medical Director for submission to member, provider or hospital.
Ensure 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.
Creates training materials and acts as a team trainer on new and revised policies and criteria.
Acts as a subject matter expert (SME) within the department. Handles escalated issues from Concurrent Review Nurses.
Performs department and clinical audits at the request of management.
Performs special duties as assigned.
Required - A High School Diploma or GED
Preferred - A Bachelor's Degree in a related area
Required - 4 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. 4 years to include 1 year of acute care experience.
Required - 1 year of experience in an acute care setting (Medical)
Preferred - 4 years of experience in managed care
Ability to create, review and interpret treatment plans
Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Knowledge of community, state and federal laws and resources
Ability to review multiple type of appeal files (member/provider, retro/pre-service, etc).
Ability to build high morale and obtain group commitments to goals and objectives.
Capability of working extra time and/or be "on-call" at request of management.
IRR Appeals Reviewer Test - >85% passing score.
Ability to consistently meet the established production goals (over 30 files/week)
Licenses and Certifications:
Required - One of the following licenses: LPN, RN, LSW, LMHC, LCSW
Required - Proficiency working in Microsoft Word, Excel and Outlook
Required - Experience working with a Healthcare Management Systems
Ability to use proprietary healthcare management system