Clinical - Clinical Review Clinician - Appeals - J00923

Job Profile Summary

Position Purpose:
Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor s degree in Nursing and 2 4 years of related experience.

Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:
LPN - Licensed Practical Nurse - State Licensure required or
LVN - Licensed Vocational Nurse required or
RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
LCSW- License Clinical Social Worker required or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Marital and Family Therapist (LMFT) required or
Licensed Psychologist required
For Health Net of California: RN license required

Responsibilities
Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal

Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards

Communicates with members, providers, facilities, and other departments regarding appeals requests

Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards

Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests

Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned

Complies with all policies and standards

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Job Profile Summary Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor s degree in Nursing and 2 4 years of related experience. Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required For Health Net of California: RN license required Responsibilities Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards Communicates with members, providers, facilities, and other departments regarding appeals requests Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards
Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Shared Services Medicare Appeals department located within EBOS. We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. These reviews determine if members can/did receive medically necessary services. Department is launching a BPO with expected team impacts. Resignations have come in and the need for this request is to mitigate staff leaving until BPO is up and running.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?			Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on. Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations. Work closely with the MD team to make final decisions on cases. The clinical team works closely with their supervisors and senior clinicians on the team for support. Team does have group chats on Teams for routine questions. Team works closely together along with the coordinator team who owns end to end process on cases. Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.
Candidate Requirements
Education/Certification	Required:				Preferred: Associate in nursing, Bachelor s in nursing or higher.
Licensure	Required: RN, LPN				Preferred: LVN
Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals Nice to haves: Medicare Appeals Experience Disqualifiers: Not having a valid/active RN/LPN license Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases Best vs. average: Productivity expectations are set based on platform.
Top 3 must-have hard skills stack-ranked by importance			1	Utilization Management or Appeals review background (1 plus year)
			2	Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
			3	Retrospective claims clinical reviews (1 plus year)
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations			Projected Manager Candidate Review Date:			1-2 days post shortlisting
			Type of Interviews:			Teams- Cameras On
			Required Testing or Assessment (by Vendor):
Next Steps