Appeals Processing Analyst- RN

The job profile for this position is Appeals Processing Analyst, which is a Band 2 Senior Contributor Career Track Role.

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Delivers specific delegated tasks assigned by a supervisor in the Utilization Management job family. Completes day to day Utilization Review tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. Requires a RN.

This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm - Monday through Friday and Alternating Weekends as Required

Job Requirements include, but not limited to:

• Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C
• Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.
• Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.
• Review, research and understand how  request for plan services and claims submitted by consumers (members)  and physicians/providers was processed and determine why it was denied
• Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.
• Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director.                                           
• Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response
• Complete necessary documentation final determination of the appeals using the appropriate system applications, templates, communication process, etc.
• Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)
• Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance 
• Adhere to department workflows, desktop procedures, and policies.
• Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.
• Read Medicare guidance documents report and summarize required changes to all levels department management and staff.
• Support the implementation of new process as needed.
• Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .
• Understand and investigate billing issues, claims and other plan benefit information. .
• Additional duties as assigned.

Qualifications

• Education: Active RN license
• 3-5 years’ experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service
• Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of  Local Coverage Determinations, National Coverage Determinations,  Medicare  claim process and plan rules  along with working with of ICD9, ICD10
• Experience with claims processing and application of member benefits related to the Explanation of Coverage
• Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.
• Must have the ability to work objectively and provide fact based answers with clear and concise documentation.
  Proficient in Microsoft Office products (Access, Excel, Power Point, Word).
• Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.
• Ability to multi-task and meet multiple competing deadlines.
• Ability to work independently and under pressure.
• Attention to detail and critical thinking skills.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

Please note that you must meet our posting guidelines to be eligible for consideration.  Policy can be reviewed at this link.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.