RN Case Manager- Appeals

Daily Responsibilities:  

• This candidate needs to be comfortable in an office setting. The hiring manager wants to stay away from candidates coming straight from clinical as they are not used to a desk job and no patient interaction.

• This person will be reviewing cases to make sure the correct medical actions were taken and denying and appealing those cases. They will be writing letters and correspondence and sitting at a computer all day.

• Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met

• Review clinical data to determine claim payment based on company policies and

• National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review

• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received

• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions

• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution

• Gather and prepare case information for Administrative Law Hearings

• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database

• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements.