Clinical Appeals-RN

Day to Day Responsibilities:

The Clinical Appeals RN performs the clinical appeals in accordance with internal policy and procedures, as well as regulations and timeframes set forth by the New York State Medicaid Contract.

The Clinical Appeals RN is responsible for timely assembly of the materials used for decision making from the Plan’s prior payment or service denial, and the thorough evaluation of those records and any new appeal information or documentation that was submitted with the appeal according to Medicaid coverage guidelines and other acceptable medical criterion.

 Additionally, the Clinical Appeals RN is responsible for preparing clinical information and other supportive coverage guidelines to present to the Medical Director or external Physician Reviewer for their reconsideration (appeal) determination.

• Exhibits a thorough understanding of Medicaid Contract and Managed Care Legislation in regard to appeals processing guidelines.

• Thoroughly reviews all supporting information and requests additional information and/or medical records as required. 

• Applies contract language, benefits and covered services in researching and deciding the outcome of appeals. 

• Analyzes cases and identifies those which require escalating or expedited review, and adheres to associated timeframes for timely completion of the appeal review process. 

• Evaluates the necessity, appropriateness of medical services and procedures requested; then forwards all appeal cases with supportive criteria, guidelines, and protocols to an internal or external Physician Reviewer in the appropriate specialty for final determination. 

IF IS JOB OPPORTUNITY IS FOR YOU, GIVE ME A CALL AT 321-574-6926 ASAP!