Clinical RN Nurse Appeals Lead New

011540 CCA-Appeals & Grievances



Position Summary

Investigate and resolve medical necessity member appeals. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements. Maintain all appeals documentation according to external agency requirements.



Supervision Exercised

• None
  
  
  
  

Essential Duties And Responsibilities

• Extrapolates and summarizes medical information for medical director, consultants, and other external review.
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director as needed.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Documents and logs appeal/grievance information on relevant tracking systems.
• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, Interqual, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing appeals.
• Participate in telephonic Administrative Law Judge Hearings and present oral arguments as needed.
• Generates appropriate written correspondence to providers, members, and regulatory entities.
• Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication.
• Identify potential quality of care issues within medical appeals; escalate as appropriate.
• Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary.
• Participate in departmental audits in preparation of regulatory site visits.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA’s mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self- identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
• Complete required compliance training in a timely manner
• Review Code of Conduct at least annually and promote and enforce CCA’s Code of Conduct Promote and enforce CCA’s compliance program
• Adhere to CCA’s Policy & Procedures
• Promptly, in good faith, report any instances of suspected fraud, waste, and abuse; suspected privacy and/or security incidents; or any compliance concerns identified
• Ensure confidentiality of member and company proprietary information is maintained
  
  
  
  

Working Conditions

• Office Environment
  
  
  
  

Required Education

• Current active unrestricted Massachusetts RN license.
  
  
  
  

Desired Education

• AS/BS in Nursing preferred.
  
  
  
  

Required Experience

• 3+ years of nursing experience in a Managed Care setting is required.
  
  
  
  

Desired Experience

• 5+ years of clinical nursing experience is strongly preferred.
• Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred.
  
  
  
  

Required Knowledge, Skills & Abilities

• Requires strong oral, written, and interpersonal communication skills, problem-solving skills, and analytical skills.
• Proficiency in Microsoft Word, Excel, and Outlook
• Strong interpersonal, verbal, and written communication skills preferred
• Ability to work independently and make decisions
• Comfort working in a team-based environment
• Working knowledge of and ability to navigate through the healthcare system
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
  
  
  
  

Language(s)

• English
  
  
  
  

Other

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
• While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear
• The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
• The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus