Independence Blue Cross LLC
Clinical Appeals Coord (Legal)
This Appeal Coordinator position is responsible for medical appropriateness review of and the coordination of appeal reviews by peer consultants. The primary responsibility of the Patient Care Coordinator-Appeal Coordinator is to evaluate the medical necessity of proposed and/or delivered plans of treatment by reviewing the member's medical documentation. The Appeals Coordinator will use clinical support criteria and/or established department or medical policy and plan benefits to evaluate proposed delivery plans of treatment. When appropriate, the Appeal Coordinator will coordinate the last level of appeal with the group. The Appeals Coordinator also acts as a patient advocate for members, when accessing the member's appeal rights. The Appeal Coordinator maintains quality of care standards and limits the member's exposure to medically unnecessary and inappropriate treatment.
· Coordinates all levels of medical, pharmacy, and mental health appeals
· Performs review of medical documentation using Interqual criteria, Medical Policy, or other appropriate criteria to establish the need for inpatient, continued stay, length of stay, procedures and ancillary services
· Ensures all assigned appeals are completed within the compliance timeframes
· Review treatment plan documentation to obtain clarifying information with provider if needed
· Refers cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member's medical condition and the potential ongoing needs of the member.
· Provides verbal notification of determination to the appellant for urgent care/expedited appeal requests
· In accordance with NCQA, ERISA, and applicable state guidelines, generates appropriate correspondence to inform the applicable parties of the appeal determination
· Identifies and refers cases for case management and disease management.
· Appropriately refers cases to the Quality Management Department and/or Clinical Services Supervisor when indicated.
· Completes appeal disclosures as applicable
· Participates in the process of educating providers on managed care policies and appeal processes
· Provides subject matter expertise and assistance in development of departmental policies and procedures and training
· Maintains knowledge of NCQA standards, Interqual Criteria, federal and state government regulations related to appeals
· Provides clinical support to the Appeals Specialist team
· Works collaboratively with peers and other associates both within the Appeals Department and other business areas
· Performs activities in accordance with corporate and departmental policies and procedures
· Adheres to production and quality standards, and applicable state and federal regulations, and accreditation standards
· Provides on call appeal coverage for holidays and weekends
· Performs additional job-related duties as assigned
Bachelor of Science in Nursing Preferred
Active Unrestricted PA RN License Required
Must live in one of the following states: PA, NJ, DE
Experience, Knowledge, & Skills
• Minimum Five years clinical experience or equivalent (Intensive Care, Trauma, Home Health a plus)
• Medical management precertification/retrospective review experience required
• Oriented in current trends of medical practice
• Strong problem solving abilities, excellent organizational and planning skills
• Ability to work independently and provide positive resolution of complex medical and interpersonal challenges
• Highly professional interpersonal skills for internal and external contacts, particularly in situations where determinations are in conflict with treating providers proposed treatment plans.