Handling all Utilization Management medical appeal cases
Ensure that timeliness guidelines are met and appeals handled in compliance with regulatory requirements
Provides mentoring and clinical liaison support to appeals staff
Assesses patient's clinical need against established guidelines and standards
Evaluates necessity, appropriateness and efficiency of medical services by inpatient facilities
Prepares medical records for review by Medical Director
Investigates and resolves complicated appeals, coordinating with legal department as necessary
Prepares and presents appeals to Appeals Committee
Conducts presentations of appeals process to internal customers
Plans appropriate allocation of resources to provide quality patient care
Documents accurately and comprehensively based on the standards of practice
Interacts and communicates with facilities, physicians and/or members/families
Evaluates care by problem solving and participating in the quality improvement program
Facilitates the external review process.
Provides 24/7 on-call appeal support as scheduled
Actively participates in enterprise meetings as managements' proxy as necessary

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 ability to work in a high volume environment with moderate supervision
Require ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making
Requires ability to utilize a personal computer and applicable software.
Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers.

Appeals Resolution Analyst II, RN

Key skills