Job DescriptionResponsible for the resolution of clinical appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical and administrative criteria and policies in line with regulatory and accreditation requirements for member and provider appeals and disputes. Independently coordinates the clinical resolution with internal and external clinician and medical management support as required. Documents and summarizes to all parties involved in the case investigation's results.
- Communicates with medical office personnel to obtain pertinent clinical history and information. Documents and summarizes clinical or administrative rationale for all approvals and denials to all parties involved in the case.
- Implements quality assurance plans for specific contracts and coordinates this activity with the appropriate account managers or dedicated quality assurance staff.
- Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews.
- Participates in on-going training programs to ensure quality performance is in compliance with applicable standards and regulations.
- Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures.
- Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes.
- Documents communications with medical office staff and/or MD provider as required.
- Refers cases to appropriate internal reviewers according to the business needs of the particular health plan.
- Researches requests for post-determination review and categorizes each for processing based on the applicable health plan policies and procedures.
- Reviews and coordinates documentation; interprets data obtained from clinical records and ensures appropriate clinical criteria and policies are aligned with regulatory and accreditation requirements for members and providers.
- Tracks all post-determination cases to completion to ensure compliance.
- Trains new employees on the appeals and de-certification process as needed.
- Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals.
General Job Information
Job FamilyQuality Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date8/19/2019
Date Requisition Created8/19/2019
EducationAssociates: Nursing (Required)
License and Certifications - RequiredLPN - Licensed Practical Nurse - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
- Managed care or utilization management experience preferred.
- Requires 1-3 years' experience and is a LPN.
- Must be able to exercise independent and sound judgment in clinical decision making.
- Must be computer literate and able to navigate through internal and external computer systems.
- Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities are a must.
- Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally.
- Strong written and verbal communication skills.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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