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HF Management Services, LLC

Appeals and Grievances Clinical Specialist/ Quality Of Care

УдалённоUnited States только
Опубликовано
Занятость
Полная занятость
Размер компании
Крупная
$83.1k–$120.4k/yr
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Доступно для: US only. Укажите, откуда вы работаете, чтобы проверить доступность.

Коротко по делу

RN-preferred clinical specialist for appeals & grievances managing full case development and resolution (medical necessity, prior approval, continued stay, appeals). Remote role with requirement to work from/attend meetings in NY (100 Church St) or Lake Mary, FL; must know utilization review guidelines and care management systems.

Ключевые навыки

Appeals & Grievances case development

Обязательные навыки

Utilization Review Guidelines (NYS ART 44 and 49 PHL)InterQualMillimanMedicare local coverage guidelinesMicrosoft WordMicrosoft Excelcorporate emailvirtual filing systemCCMSTruCareHylandcase managementclaims processing

Желательные навыки

Bachelor’s degreeQuality of Care experienceRN (preferred)

Чем предстоит заниматься

  • Responsible for case development and resolution of clinical cases such as Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services.
  • Research issues and reference HF internal health plan policies and procedures to frame decisions.
  • Interpret regulations and resolve cases making critical decisions.
  • Update file documentation such as file notes and case summary.
  • Manage all duties within regulatory timeframes.
  • Communicate effectively to hand-off and pick-up work from colleagues.
  • Work within a framework that measures productivity and quality for each Specialist.
  • Prepare cases for Medical Director Review ensuring all pertinent information is obtained and presented.
  • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process.
  • Manage Department of Health (DOH) and executive complaints as needed.
  • Handle clinical claim appeals from participating and non-participating providers.

Что требуется

  • RN
  • Quality Of Care Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
  • Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
  • Ability to work independently on several computer applications such as Microsoft Word and Excel, corporate email and virtual filing system (ie. Macess).
  • Experience with care management systems, such as CCMS, TruCare and Hyland.
  • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.
  • Bachelor’s degree (preferred).

Преимущества

  • medical coverage
  • dental coverage
  • vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions
  • travel & expenses covered according to policy for required travel
HealthcareКрупная
$83.1k–$120.4k/yr