Specialist, Clinical Appeals

About the Role:

This position requires a licensed registered nurse. The Clinical Appeals Specialist (CAS) is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Clinical Appeals Specialist will follow the Agency for Health Care Administration’s (AHCA) appeal and Fair Hearing policy and corresponding procedures for all enrollee appeals and Fair Hearings. This position provides FCC with the timeliness of the appeal and Fair Hearing process, all correspondence in the response and assistance to the enrollees in pursuing an appeal or Fair Hearing, to assure that sound, compelling factual arguments for enrollee advocacy  is  maintained throughout the process; and, the actual day-to-day processing of enrollee appeals and Fair Hearings. The Clinical Appeals Specialist will also be required to attend all Fair Hearings, handle all AHCA related statutory reporting and audit-related correspondence, and other administrative duties as required.

Minimum Qualifications:

• Active, Unrestricted Florida RN License is required.
• Bachelor's degree in healthcare administration, nursing, or related field preferred
• 5 years of experience in Managed Care organization
• 5 years of experience in Utilization Mangement or Case Management or Care Coordination
• 3 years of experience in Grievance and Appeal
• 3 years of experience as a Clinical Nurse in an Acute or Chronic Care setting
• Ability to communicate effectively with healthcare providers, patients, and insurance companies

Preferred Qualifications:

• Knowledge of Florida Medicaid preferred
• Fluency in Spanish preferred
• Knowledge of InterQual Level of Care Criteria or Milliman & Robertson criteria

• Knowledge of Medicare Part A, B, C and D
  
  

Responsibilities:

• Review and analyze medical records, claims, and appeals to ensure compliance with regulatory requirements and medical policies
• Work closely with healthcare providers, patients, and insurance companies to resolve disputes and ensure timely and accurate payment of claims
• Interpret complex medical information and apply it to the appeals process
• Maintain accurate records and documentation of all appeals and related activities
• Collaborate with other members of the healthcare team to identify opportunities for process improvement and increased efficiency

Skills:

In this role, you will utilize your strong analytical and problem-solving skills to review and analyze medical records, claims, and appeals. Your ability to interpret complex medical information and apply it to the appeals process will be critical. You will also need to communicate effectively with healthcare providers, patients, and insurance companies to resolve disputes and ensure timely and accurate payment of claims. Additionally, your knowledge of medical terminology, coding, and billing practices will be essential in this role. Finally, you will collaborate with other members of the healthcare team to identify opportunities for process improvement and increased efficiency.