SUMMARY The Clinical Appeals Nurse is responsible for investigating and processing medical necessity appeals from members and providers to payers. Possesses the ability to conduct research on standards or practice, regulations, and policy relevant to any case. Responsible for overturning denied claims, upholding the denials and submitting cases to the Medical Director for review. Possesses the ability to communicate clearly and concisely, both verbally and in writing and utilize computer and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Ensures timely and accurate processing of all denials. Will ensure that denials are processed according to KPC Policies and meet all Health Plan, Federal and State requirements. Perform other duties as assigned.
REQUIREMENTS- Current active California RN license required
- Minimum 2 years of experience in a managed care healthcare setting
- Minimum 2 years of Utilization Management
- Experience with payer specific medical guidelines and how to apply them in an appeal
- Experience using MCG and/or InterQual guidelines
DUTIES AND RESPONSIBILITIES- Conduct and investigate member and provider medical necessity appeals
- Review prospective, inpatient, and retrospective medical records of denied services for medical necessity
- Ensures appeals and grievances are resolved in a timely manner
- Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
- Generate written correspondence to providers and members to achieve maximum overturn rate
- Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
- Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
- Presents recommendations based on clinical review, criteria, and organizational policies
- Complies with HIPAA and other compliance requirements to protect patient confidentiality
- Contact and educate patients and guarantors regarding necessary steps to resolve an outstanding insurance balance while providing exemplary customer service
