Clinical - Clinical Review Clinician - Appeals

Position Purpose:

Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Education/Experience:

Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

Knowledge of NCQA, Medicare and Medicaid regulations preferred.

Knowledge of utilization management processes preferred.

License/Certification:

LPN - Licensed Practical Nurse - State Licensure required or

LVN - Licensed Vocational Nurse required or

RN - Registered Nurse - State Licensure and/or Compact State Licensure requiredPrepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal

Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards

Communicates with members, providers, facilities, and other departments regarding appeals requests

Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards

Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests

Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices

Performs other duties as assigned

Complies with all policies and standards

EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."

Story Behind the Need - Business Group & Key Projects

Health plan or business unit

Team culture

Surrounding team & key projects

Purpose of this team

Reason for the request

Motivators for this need

ny additional upcoming hiring needs?

Buckeye Client

Cohesive; works closely together (including with Sups) to ensure any assistance needed

Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Backfill for temp, Megan Moss, who retired her role on 8/14 Typical Day in the Role

Daily schedule & OT expectations

Typical task breakdown and rhythm

Interaction level with team

Work environment description

8a-5p (NO OT req)

(Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system).

Behavior and accountability and ability to pivot when new priorities come up)

Emails and Team chats to ensure communication is reached and assistance is available, if needed Compelling Story & Candidate Value Proposition

What makes this role interesting?

Points about team culture

Competitive market comparison

Unique selling points

Value added or experience gained

The ability to be engaged with members to allow members to address overall issues about their care/coverage

Strong collaboration and positive interactions between team and leadership

N/

Same as 1 st point Candidate Requirements Education/Certification Required: LPN Minimum Preferred: RN-Not required Licensure Required: LPN minimum Preferred:

Years of experience required

Disqualifiers

Best vs. average

Performance indicators Must haves: (SEE NUMBERED SECTION BELOW)

Nice to haves:

Direct patient care experience

Longevity at positions

Writing appeal or authorization outcome letters.

experience with Trucare and/or Amisys systems is greatly valued.

• Utilization review nurse, appeal review nurse and direct patient care experience.

Disqualifiers: Not possessing the must haves

Performance indicators: (Metrics: • 10 to 15 appeals a day after training. Not letting any items in work queues go over compliance Turn Around Time.)

Best vs. average:

Top 3 must-have hard skills

Level of experience with each

Stack-ranked by importance

Candidate Review & Selection 1 Experience with Utilization Review/Management--2 yrs 2 Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case. 3 Review medical code data and records to determine whether a denial is

warranted.

4

Utilizing multiple appeals/claims systems to conduct medical reviews. 5 Comfortable with Microsoft office programs and utilizing systems to input medical criteria. Candidate Review & Selection

Shortlisting process

Second touchpoint for feedback

Interview Information

Onboard Process and Expectations Projected HM Candidate Review Date: 2 business days Number and Type of Interviews: 1 via Teams on camer Extra Interview Prep for Candidate: No Required Testing or Assessment (by Vendor): N/ Manager Communication Preferences & Next Steps

Background Check Requirements (List DFPS or other specialty checks here) Refer to BGC Matrix

Do you have any upcoming PTO? TBD

Colleagues to cc/delegate No