Mindlance
Clinical - Clinical Review Clinician - Appeals
Mindlance, Columbus, Ohio, United States, 43224
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.
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.