Handling all Utilization Management medical appeal cases
Ensuring that timeliness guidelines are met and appeal handled in compliance with regulatory requirements
Providing mentoring and clinical liaison support to appeals staff
Assessing patient's clinical need against established guidelines and standards
Evaluating the necessity, appropriateness and efficiency of medical services and procedures
Performing review of medical records and preparing for review by Medical Director
Investigating and resolving complicated appeals
Coordinating with legal department as necessary
Preparing and presenting appeals to Appeals Committee
Conducting presentations of appeals process to internal customers
Plans appropriate allocation of resources to provide quality patient care
Documenting accurately and comprehensively
Interacting and communicating with facilities, physicians and members/families
Evaluating care by problem solving and analyzing variances
Facilitating the external review process with the IURO and IRO
Providing 24/7 on call appeal support as scheduled
Actively participating in enterprise meetings as management's proxy

High School Diploma/GED required
Bachelor degree in health care management preferred or relevant experience in lieu of degree
Requires 2 years clinical experience
Requires 3 years experience in the health care delivery system/industry
Requires a Registered Nurse License
Requires working knowledge of principles of utilization management
Requires knowledge of health care contracts and benefit eligibility requirements
Requires knowledge of hospital structures and payment systems
Requires excellent oral and written communication skills
Requires the ability to work in a high volume environment with moderate supervision
Requires the ability to utilize a personal computer and applicable software
Strong negotiation skills
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

Appeals Resolution Analyst II – RN

Key skills