RN, Appeals Clinical Coordinator

Job Description The RN, Appeals Clinical Coordinator analyzes and resolves appeals received from members, providers, and government entities.

This individual performs advanced clinical case review by evaluating the appropriateness of medical care and service provided to members using clinical guidelines and VIVA HEALTH policies.

This position will serve as a Subject Matter Expert and assist other clinical reviewers in the department as needed.

Additionally, this role will assist with commercial complaints and provider appeals as needed.

Key Responsibilities * Conduct clinical review and evaluation of Medicare member appeals, including non-participating provider appeals and participating provider appeals, using considerable clinical judgment, independent analysis, and detailed knowledge of medical policies, clinical guidelines, coverage criteria, and member benefit plans to determine the appropriateness of care.

* Summarize cases including articulation of the provider or member's perception, initial denial determination and notification, analysis of medical records, and application of all applicable policies, guidelines, benefit plans, laws, and rules & regulations.

* Assist other clinical reviewers in the department with challenging cases and provide back-up as needed.

* Identify system or individual care issues that resulted in failure to provide appropriate care to members or meet service expectations.

Work with department management to address these issues.

* Process appeals according to federal and state regulations and internal, organizational policies and procedures.

* Identify and work with department management to implement training, process improvement, and other ways to maximize plan performance and provider & member satisfaction.

* Monitor data for trends and complete root cause analysis.

REQUIRED: * Bachelor's Degree or Associate's Degree from an accredited program of professional nursing (ADN or BS/BSN) * 3 - 5 years' experience in a clinical or healthcare setting * Experience working with the elderly and disabled population and/or Medicaid Managed Care * Current RN License in good standing with the State of Alabama Board of Nursing * Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks * Ability to meet established productivity, schedule adherence, and quality standards * Ability to use critical thinking skills to develop solutions to clinical and non-clinical issues using fact-based decision-making * Proficient in the Microsoft Office suite of products with a strong proficiency in Microsoft Excel and Word * Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision * Proficient in using standardized clinical guidelines as well as utilization management tools, including Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), Interqual, and Milliman guidelines * Ability to effectively analyze, interpret, apply, and communicate policies, procedures, and regulations * Ability to interact with all departments within the Company, outside vendors, and government regulatory agencies, including MDs and MD office staffs PREFERRED: * 3 years' experience in Medicare Managed Care * 1 year experience processing appeals or in utilization management or quality management * Knowledge of Medicare and commercial regulations of the Medicare Managed Care Manual * Knowledge of CPT/HCPC and ICD10 coding, procedures, and guidelines * Knowledge of the CMS and Palmetto websites