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Appeals and Grievance /Utilization Management Nurse - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Federal Way, WA Federal Way, Washington |
About this job
Summary
The Appeals & Grievance (A&G) Utilization Management RN Nurse Specialist is a hybrid role where the Nurse is responsible for managing clinical appeals for denials and also providing medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures.
In the A&G role, the individual is responsible for receiving, investigating, and responding both verbally and in writing to member and provider appeals, including reviewing and making decisions on supporting clinical information. He/She will analyze, review and evaluate clinical appeals and supporting clinical information to overturn and/or recommend uphold of coverage decisions.
The Utilization Management role includes providing prior authorizations, concurrent review, proactive discharge/transition planning, appropriate referral to case management, and high dollar claims review at least but not limited to 50% time in this job role.
This individual will be a clinical problem solver with facilities, providers, and support resolution of issues concerning members, benefits, program definition and clarification.
Essential Duties and Responsibilities
* Adhere to all company compliance standards and maintain confidentiality of member, physician and employee information.
* Foster strong professional working relationships with others in the company, delegates and external agencies to aid in the implementation of cross-functional cooperation and improvement of interdepartmental processes.
* Work with Medical Directors, VP of Quality and Care Management, Care Management team, A&G team, Claims and other cross functional teams.
* Represents QualChoice Health Plan Services in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers.
* Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
* Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program.
* Provides clinical support to non-clinical Care Management Coordinators as relates to Prior Authorization requests.
* Assists in the identification and reporting of Potential Quality of Care concerns.
* Provides back up for other members of the Care Management Department when needed.
* Maintains accurate records of all communications.
* Perform other duties as required or assigned.
Appeals & Grievance Management: (Approximate 50%)
* Collaborate with healthcare providers and CMS to promote quality and accurate decisions according to Medicare guidelines and to promote effective use of resources for the most complex or elevated medical issues.
* Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products.
* Collaborate with providers and provider outreach department to facilitate education and training on appeals process and clinical decision making.
* Review pre and post service claims for clinical eligibility for coverage as prescribed by the Plan benefits.
* Load approvals into the system and be responsible for accurately documenting determinations.
* Reviews all supporting information thoroughly and requests additional information as required.
* Identifies those cases which must be expedited, and adheres to associated timeframes for completion of the process.
* Evaluate and review potential quality of care concerns as necessary.
* Reach out to members to manage grievances as appropriate.
Utilization Management: (Approximate 50%)
* Conducts prospective review of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, ancillary services, home care and out of area referrals.
* Makes clinical decisions based on established criteria (Milliman Care Guidelines) and regulatory requirements.
* As part of the hospital prior authorization process, responsible for determining "observational" vs. "acute inpatient" status.
* Prepares documentation and presents prior authorization requests to the Medical Director for additional review as necessary.
* Performs concurrent and retrospective reviews on all facility (hospital, skilled nursing facility, and acute rehabilitation) and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
* Evaluates and provides proactive feedback to member's providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate. Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds.
* Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation.
* Monitors utilization reports to assure compliance with reporting and turnaround times.
* Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation.
* Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
Education and Experience
* Active RN license, multiple state as required
* Minimum 3 years clinical experience as an RN in an acute, inpatient hospital setting
* Minimum 5 years managed care or equivalent health plan experience preferred
* Bachelor of Science in Nursing preferred
* Demonstrated experience in health plan Utilization Review, Discharge Planning, and Care Coordination preferred
* Experience using Milliman Care Guidelines preferred
* Ability to learn different systems & tools as necessary.
* Medical Coding experience/knowledge a plus
* Prior experience working in Medicare Part C and D Appeals and Medicare Advantage preferred
* Strong proficiency in Microsoft Office Word, Outlook, and Internet applications
* Established track record of working under tight deadlines and managing stressful situations.
* Must possess strong problem-solving skills and have the ability to multi-task in an effective and organized manner.
* Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary.
Certificates, Licenses and Registrations
* Active, unrestricted RN license in state of residence and multiple state as required
* Reliable transportation, auto insurance and a valid driver's license required
The Appeals & Grievance (A&G) Utilization Management RN Nurse Specialist is a hybrid role where the Nurse is responsible for managing clinical appeals for denials and also providing medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures.
In the A&G role, the individual is responsible for receiving, investigating, and responding both verbally and in writing to member and provider appeals, including reviewing and making decisions on supporting clinical information. He/She will analyze, review and evaluate clinical appeals and supporting clinical information to overturn and/or recommend uphold of coverage decisions.
The Utilization Management role includes providing prior authorizations, concurrent review, proactive discharge/transition planning, appropriate referral to case management, and high dollar claims review at least but not limited to 50% time in this job role.
This individual will be a clinical problem solver with facilities, providers, and support resolution of issues concerning members, benefits, program definition and clarification.
Essential Duties and Responsibilities
* Adhere to all company compliance standards and maintain confidentiality of member, physician and employee information.
* Foster strong professional working relationships with others in the company, delegates and external agencies to aid in the implementation of cross-functional cooperation and improvement of interdepartmental processes.
* Work with Medical Directors, VP of Quality and Care Management, Care Management team, A&G team, Claims and other cross functional teams.
* Represents QualChoice Health Plan Services in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers.
* Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
* Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program.
* Provides clinical support to non-clinical Care Management Coordinators as relates to Prior Authorization requests.
* Assists in the identification and reporting of Potential Quality of Care concerns.
* Provides back up for other members of the Care Management Department when needed.
* Maintains accurate records of all communications.
* Perform other duties as required or assigned.
Appeals & Grievance Management: (Approximate 50%)
* Collaborate with healthcare providers and CMS to promote quality and accurate decisions according to Medicare guidelines and to promote effective use of resources for the most complex or elevated medical issues.
* Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products.
* Collaborate with providers and provider outreach department to facilitate education and training on appeals process and clinical decision making.
* Review pre and post service claims for clinical eligibility for coverage as prescribed by the Plan benefits.
* Load approvals into the system and be responsible for accurately documenting determinations.
* Reviews all supporting information thoroughly and requests additional information as required.
* Identifies those cases which must be expedited, and adheres to associated timeframes for completion of the process.
* Evaluate and review potential quality of care concerns as necessary.
* Reach out to members to manage grievances as appropriate.
Utilization Management: (Approximate 50%)
* Conducts prospective review of authorization requests including selected specialties, medical treatments and services, elective hospital admissions, ancillary services, home care and out of area referrals.
* Makes clinical decisions based on established criteria (Milliman Care Guidelines) and regulatory requirements.
* As part of the hospital prior authorization process, responsible for determining "observational" vs. "acute inpatient" status.
* Prepares documentation and presents prior authorization requests to the Medical Director for additional review as necessary.
* Performs concurrent and retrospective reviews on all facility (hospital, skilled nursing facility, and acute rehabilitation) and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
* Evaluates and provides proactive feedback to member's providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate. Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds.
* Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation.
* Monitors utilization reports to assure compliance with reporting and turnaround times.
* Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation.
* Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
Education and Experience
* Active RN license, multiple state as required
* Minimum 3 years clinical experience as an RN in an acute, inpatient hospital setting
* Minimum 5 years managed care or equivalent health plan experience preferred
* Bachelor of Science in Nursing preferred
* Demonstrated experience in health plan Utilization Review, Discharge Planning, and Care Coordination preferred
* Experience using Milliman Care Guidelines preferred
* Ability to learn different systems & tools as necessary.
* Medical Coding experience/knowledge a plus
* Prior experience working in Medicare Part C and D Appeals and Medicare Advantage preferred
* Strong proficiency in Microsoft Office Word, Outlook, and Internet applications
* Established track record of working under tight deadlines and managing stressful situations.
* Must possess strong problem-solving skills and have the ability to multi-task in an effective and organized manner.
* Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary.
Certificates, Licenses and Registrations
* Active, unrestricted RN license in state of residence and multiple state as required
* Reliable transportation, auto insurance and a valid driver's license required