What are the responsibilities and job description for the Clinical Appeals Specialist position at Capital District Physicians Health Plan Inc?
Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.
The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process that meets state, federal, accreditation and other regulatory requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations about appropriateness of care, and expedite cases within established criteria and contract requirements. This individual will be responsible for tracking, trending and monitoring of appeals, grievances, NYS external review, and making recommendations for change.
QUALIFICATIONS:
The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process that meets state, federal, accreditation and other regulatory requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations about appropriateness of care, and expedite cases within established criteria and contract requirements. This individual will be responsible for tracking, trending and monitoring of appeals, grievances, NYS external review, and making recommendations for change.
QUALIFICATIONS:
- Registered Nurse, Physician Assistant or Nurse Practitioner, with valid state registration or license required. LPN and 3 years of Appeals experience in lieu of RN degree.
- Associates degree required. Bachelor's degree preferred.
- Minimum three (3) years of clinical experience required.
- Minimum one (1) year of quality/utilization review experience required.
- Experience with research, data retrieval, data analysis, and case summarization required.
- Experience with ICD diagnosis, CPT coding practices, and DRG principles required.
- Experience in a health care setting preferred.
- Experience in appeals processing is preferred.
- Experience with Microsoft Office, including Word, Excel, Outlook and PowerPoint is required.
- Demonstrated ability to organize and analyze trends.
- Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
- Demonstrated ability to handle multiple, competing priorities.
- Demonstrated ability to pro-actively identify problems, as well as recommend and/or implement effective solutions.
- Excellent verbal and written communications skills.
- Demonstrated ability to work with and maintain confidential information.
- Flexibility to adapt to a changing and fast-paced environment.
CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.
CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at https://www.cdphp.com/about-us/jobs/benefits.
As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.
CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.
As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.
