Appeals Reviewer Veteran Job Description Samples

Results for the star of Appeals Reviewer Veteran

Clinical Appeals Reviewer - Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA Or Atlanta, GA Only - Veteran's Welcome

Position Description: Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true.

Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our Service Centers, improve our Service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas:

Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions, and treatments; helping them to navigate the system, finance their Healthcare needs, and stay on track with their Health goals. No other business touches so many lives in such a positive way.

And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation, and Performance. Primary Responsibilities: Triage requests into correct categories

Document request as A & G Correspondence or A & G AppealOperate with high attention to detail when performing various data entry tasks

Prioritize work based on due date and run applicable work list reports to monitor workload

Plan, prioritize, organize and complete work to meet assigned deadlines

Determine if appeal is clinical or administrative and ensure correct letter template is utilized

Select, update and send department specific attachments and / or enclosure(s)Send out written notification as indicated under appeals policies compile IRO packets

Solve moderately complex problems individually or in a team setting

Work on high level tasks under management supervision / guidance

Adhere to state and federal guidelines with processing appeals

Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes Required Qualifications: High School Diploma / GED (or higher)1 years of Medical / Behavioral Health Appeal & Grievance experience1 years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook6 months of Claim UM (Utilization Management) experience

Must live in one of the following areas: Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA or Atlanta, GA only Preferred Qualifications:

Experience with ISET, IQ and / or UMRFamiliarity with Medical TerminologyMedical Claims experience Soft Skills: Must have exceptional multi - tasking skills with the ability to prioritize tasks

Ability to handle a fast pace, deadlines, and competing priorities

Effective interpersonal skills, flexibility and ability to handle change

Ability to work independently as well as a member of the team

Excellent verbal, written, computation and organizational skills Strong Data Entry skills Careers with Optum. Here's the idea.

We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential.

For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Keywords: UnitedHealth Group, Optum, Healthcare, Telephonic Customer Service, Healthcare Insurance, Medical / Behavioral Health Appeals, Grievance Medical Terminology, Word, Excel, Outlook, Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, Clinical Appeals Reviewer



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Clinical Appeals Reviewer - Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA Or Atlanta, GA Only - Veteran's Welcome

Position Description: Energize your career with one of Healthcare's fastest growing companies.

You dream of a great career with a great company where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it's a dream that definitely can come true.

Already one of the world's leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our Service Centers, improve our Service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas:

Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions, and treatments; helping them to navigate the system, finance their Healthcare needs, and stay on track with their Health goals. No other business touches so many lives in such a positive way.

And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation, and Performance. Primary Responsibilities: Triage requests into correct categories

Document request as A & G Correspondence or A & G AppealOperate with high attention to detail when performing various data entry tasks

Prioritize work based on due date and run applicable work list reports to monitor workload

Plan, prioritize, organize and complete work to meet assigned deadlines

Determine if appeal is clinical or administrative and ensure correct letter template is utilized

Select, update and send department specific attachments and / or enclosure(s)Send out written notification as indicated under appeals policies compile IRO packets

Solve moderately complex problems individually or in a team setting

Work on high level tasks under management supervision / guidance

Adhere to state and federal guidelines with processing appeals

Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes Required Qualifications: High School Diploma / GED (or higher)1 years of Medical / Behavioral Health Appeal & Grievance experience1 years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook6 months of Claim UM (Utilization Management) experience

Must live in one of the following areas: Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA or Atlanta, GA only Preferred Qualifications:

Experience with ISET, IQ and / or UMRFamiliarity with Medical TerminologyMedical Claims experience Soft Skills: Must have exceptional multi - tasking skills with the ability to prioritize tasks

Ability to handle a fast pace, deadlines, and competing priorities

Effective interpersonal skills, flexibility and ability to handle change

Ability to work independently as well as a member of the team

Excellent verbal, written, computation and organizational skills Strong Data Entry skills Careers with Optum. Here's the idea.

We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential.

For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Keywords: UnitedHealth Group, Optum, Healthcare, Telephonic Customer Service, Healthcare Insurance, Medical / Behavioral Health Appeals, Grievance Medical Terminology, Word, Excel, Outlook, Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, Clinical Appeals Reviewer



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Senior Clinical Appeals Reviewer - Atlanta, GA, Chicago, IL, Philadelphia, PA, Or St. Louis, MO Only

Position Description: Energize your career with one of Healthcare’s fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true.

Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our Service Centers, improve our Service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas:

Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions, and treatments; helping them to navigate the system, finance their Healthcare needs, and stay on track with their Health goals. No other business touches so many lives in such a positive way.

And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation, and Performance. Employees in this function are responsible for providing expertise or general support in reviewing, researching, investigating, negotiating, and resolving all types of Appeals and Grievances. Communicates issues, implications, and decisions with appropriate parties.

Analyzes and identifies trends for Appeals and Grievances. This includes senior-level positions with education/certification/licensure other than an RN, such as BSW, MSW, DDS, Chiropractor, Physical Therapist, etc. (Positions responsible for Claims Appeals can be found in the Claims job family.) Primary Responsibilities: Extensive work experience, possibly in multiple functions.

Work does not usually require established procedures.Work independently.Mentor others.Act as a resource for others.Coordinate others' activities. Position can be located in: Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO Required Qualifications: High School Diploma/GED.2+ years of Telephonic Customer Service experience2+ years of Healthcare Insurance experience1+ year of professional Appeals experience

Knowledge of Medical TerminologyAbility to create, copy, edit, send & save utilizing Word, Excel & OutlookMust live in or around Atlanta, GA, Chicago, IL, Philadelphia, PA, or St. Louis, MO. Preferred Qualifications: Bachelor's Degree or HigherExperience in a professional Leadership role Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.Keywords: UnitedHealth Group, Optum, Healthcare, Telephonic Customer Service, Healthcare Insurance, Appeals, Medical Terminology, Word, Excel, Outlook, Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, Senior Clinical Appeals Reviewer 7f4bcf13-9f23-4e36-9d3a-c83bb289cc62 Senior Clinical Appeals Reviewer - Atlanta, GA, Chicago, IL, Philadelphia, PA, or St. Louis, MO onlyGeorgia-Atlanta729157



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Clinical Appeals Reviewer - Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA Or Atlanta, GA Only

Position Description: Energize your career with one of Healthcare’s fastest growing companies.

You dream of a great career with a great company where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true.

Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our Service Centers, improve our Service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas:

Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions, and treatments; helping them to navigate the system, finance their Healthcare needs, and stay on track with their Health goals. No other business touches so many lives in such a positive way.

And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation, and Performance. Primary Responsibilities: Triage requests into correct categories

Document request as A & G Correspondence or A & G AppealOperate with high attention to detail when performing various data entry tasks

Prioritize work based on due date and run applicable work list reports to monitor workload

Plan, prioritize, organize and complete work to meet assigned deadlines

Determine if appeal is clinical or administrative and ensure correct letter template is utilized

Select, update and send department specific attachments and / or enclosure(s)Send out written notification as indicated under appeals policies compile IRO packets

Solve moderately complex problems individually or in a team setting

Work on high level tasks under management supervision / guidance

Adhere to state and federal guidelines with processing appeals

Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes Required Qualifications: High School Diploma / GED (or higher)1+ years of Medical / Behavioral Health Appeal & Grievance experience1+ years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook6+ months of Claim UM (Utilization Management) experience

Must live in one of the following areas: Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA or Atlanta, GA only Preferred Qualifications:

Experience with ISET, IQ and / or UMRFamiliarity with Medical TerminologyMedical Claims experience Soft Skills: Must have exceptional multi - tasking skills with the ability to prioritize tasks

Ability to handle a fast pace, deadlines, and competing priorities

Effective interpersonal skills, flexibility and ability to handle change

Ability to work independently as well as a member of the team

Excellent verbal, written, computation and organizational skills Strong Data Entry skills Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.Keywords: UnitedHealth Group, Optum, Healthcare, Telephonic Customer Service, Healthcare Insurance, Medical / Behavioral Health Appeals, Grievance Medical Terminology, Word, Excel, Outlook, Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, Clinical Appeals Reviewer 4e0b6ea7-7581-48c5-a653-617cb977ad44 Clinical Appeals Reviewer - Schaumburg, IL, Philadelphia, PA, St Louis, MO, San Francisco, CA or Atlanta, GA onlyIllinois-Schaumburg729156



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Medical Appeals Reviewer

The Consultant is responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations. Perform independent review of favorable and partially favorable Administrative Law Judge determinations in accordance with the Part A, Part B, and DME Medicare regulations to determine if there are errors in the application of law or evidence

Research issues using federal law, federal regulations and CMS policy

Summarize policy legal issues to be submitted to the Medicare Appeals CouncilWork directly with federal government entities and contractors in regards to appeals and other special initiatives as requests from other government entities dictate

Monitor timeliness of reviews to ensure timely effectiveness in order to meet required CMS standards

Coordinate and assist in the development and maintenance of written procedures for consistency of reviews and training of new personnel

Perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary

Meet or exceed all performance standards established for this position and department

Performs other duties as assigned by leadership Registered Nurse degree with active license in SCBSN preferred2 years of related experience required

Experience in general medical care of patients preferred

Knowledge of health regulations, guidelines and coverage issues

Knowledge of statistical terminology and use of statistics

Excellent organizational, written, and verbal communication skills

Ability to perform comfortably in a fast-paced, deadline-oriented work environment

Ability to work as a team member, as well as independently

Four year nursing degree preferred; Medicare Medical Review or appeals experience in Medicare Part A, Part B and/or DME preferred; Experience in geriatric or general medical care of patients preferredA committed and diverse workforce is our most important resource. MAXIMUS is and Affirmative Action/Equal Opportunity Employer. MAXIMUS provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status. - provided by Dice Medical Appeals Reviewer


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Senior Clinical Appeals Reviewer - Atlanta, GA, Chicago, IL, Philadelphia, PA, Or St. Louis, MO Only

Position Description: Energize your career with one of Healthcare’s fastest growing companies.

You dream of a great career with a great company - where you can make an impact and help people. We dream of giving you the opportunity to do just this. And with the incredible growth of our business, it’s a dream that definitely can come true.

Already one of the world’s leading Healthcare companies, UnitedHealth Group is restlessly pursuing new ways to operate our Service Centers, improve our Service levels and help people lead healthier lives. We live for the opportunity to make a difference and right now, we are living it up. This opportunity is with one of our most exciting business areas:

Optum - a growing part of our family of companies that make UnitedHealth Group a Fortune 6 leader. Optum helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions, and treatments; helping them to navigate the system, finance their Healthcare needs, and stay on track with their Health goals. No other business touches so many lives in such a positive way.

And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation, and Performance. Employees in this function are responsible for providing expertise or general support in reviewing, researching, investigating, negotiating, and resolving all types of Appeals and Grievances. Communicates issues, implications, and decisions with appropriate parties.

Analyzes and identifies trends for Appeals and Grievances. This includes senior-level positions with education/certification/licensure other than an RN, such as BSW, MSW, DDS, Chiropractor, Physical Therapist, etc. (Positions responsible for Claims Appeals can be found in the Claims job family.) Primary Responsibilities: Extensive work experience, possibly in multiple functions.

Work does not usually require established procedures.Work independently.Mentor others.Act as a resource for others.Coordinate others' activities. Position can be located in: Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO Required Qualifications: High School Diploma/GED.2+ years of Telephonic Customer Service experience2+ years of Healthcare Insurance experience1+ year of professional Appeals experience

Knowledge of Medical TerminologyAbility to create, copy, edit, send & save utilizing Word, Excel & OutlookMust live in or around Atlanta, GA, Chicago, IL, Philadelphia, PA, or St. Louis, MO. Preferred Qualifications: Bachelor's Degree or HigherExperience in a professional Leadership role Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.Keywords: UnitedHealth Group, Optum, Healthcare, Telephonic Customer Service, Healthcare Insurance, Appeals, Medical Terminology, Word, Excel, Outlook, Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, Senior Clinical Appeals Reviewer 7f4bcf13-9f23-4e36-9d3a-c83bb289cc62 Senior Clinical Appeals Reviewer - Atlanta, GA, Chicago, IL, Philadelphia, PA, or St. Louis, MO onlyGeorgia-Atlanta729157



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BH Clinical Appeals Reviewer

Description: HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace.

Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can email us here to request reasonable accommodations.

Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions". BASIC FUNCTION:This position is responsible for coordinating clinical appeals/grievances and complaints for Behavioral Health; reporting, monitoring, scheduling and facilitating appeals according to various regulatory requirements; analyzes appeals data, determine appeals decisions or prepare cases for Medical Director review. JOB REQUIREMENTS:* Masters- level Behavioral Health Professional (LPC or LCSW) to practice at the independent practice level with current license in good standing in state of operations.*4 years clinical experience to include implementing or administering managed care or quality assurance activities.

*Knowledge and understanding of state and federal guidelines and regulations.

*Written and verbal communication skills and facilitating skills.

*Interpersonal skills to interface with internal and external customers, including representative of Department of Insurance and government agencies in a rapport-developing manner.

*Organizational skills.

*Detail oriented. PREFERRED JOB REQUIREMENTS:

  • Bilingual in English and Spanish.

*Experience in processing appeals, denials or grievances in accordance with regulatory or accreditation requirements.

*Experience in Utilization Management or audit. LI-POST CA *CB Location:

TX - Richardson Activation Date: Wednesday, September 13, 2017 Expiration Date: Saturday, September 30, 2017 Apply Here



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Government Appeals Manager - Compliance Billing Integrity

Job Summary
The Government Appeals Manager serves as the centralized source for planning, supporting, coordinating and overseeing the government claims appeal processes for Stanford Health Care and Stanford Children's Health. The Government Appeals Manager ensures effective defense, management and submission of government payor appeals related to inpatient and outpatient claims, including Medicare and Medicaid Recovery Audit Contractor appeals.

The position is responsible for reviewing medical records for development of defense strategy, including medical necessity of inpatient stays, and compiling relevant medical record documentation and other information in support of appeal defense. Responsibilities include tracking appeals through all levels of the appeal continuum; creating, coordinating and maintaining case files; ; ensuring timely submission of appeals; calculating repayment projections; analyzing and trending appeal data; creating and submitting appeal letters; and creating and maintaining spreadsheets, benchmarks and presentation materials related to appeals data.
Essential Functions
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Specific duties and responsibilities may vary depending on department or program needs without changing the general nature and scope of the job or level of responsibility entailed.
Employees must abide by all Joint Commission requirements including, but not limited to, sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Employees must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions.
Reviews medical records for development of defense strategy, including medical necessity of inpatient stays, and compiles relevant medical record documentation and other information in support of appeal defense;
Drafts and compiles case defense strategy and relevant documentation, communicates with physicians regarding participation in defense strategies;
Reviews medical record documentation to identify, analyze, produce and timely submit all medical record documentation relevant to appeals;
Compiles and maintains case documentation files, including relevant medical and billing records, correspondence, defense strategies, and other documentation.
Analyzes, tracks and trends all appeal findings through all levels of appeal;
Oversees and ensures accuracy of government appeals databases, analyzes data and produces reports, spreadsheets and presentations regarding trending of data and predictive modeling of future appeals;
Conducts analysis and trending of data for identification of potential billing integrity risk areas, billing integrity improvement opportunities and risk reduction actions;
Analyzes appeal data for calculation of repayment projections, cost benefit of appeals and decision support;
Receives, logs, tracks, analyzes and timely responds to all government appeals correspondence;
Conducts research to ensure institutional knowledge and application of current information related to regulatory developments in government appeals, industry appeal strategies, data and trends;
Maintains knowledge and credentials sufficient to conduct medical record review and analysis.
All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status or on the basis of disability.Minimum Qualifications
Any combination of education and experience that would likely provide the required knowledge, skills and abilities is qualifying.
Education: Bachelor's degree in a work-related discipline/field from an accredited college or university; Registered Nurse or Physician preferred.
Experience: Minimum of three (3) years of progressively responsible and directly related work experience.
Licenses/Certifications: Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) or RN with direct government claims defense experience. Registered Nurse or Physician with claims defense experience preferred.
Knowledge, Skills, and Abilities:
Demonstrated ability to apply judgment and make informed decisions;
Demonstrated ability to plan, organize, prioritize work independently and meet deadlines;
Demonstrated ability to analyze and develop solutions to complex problems;
Demonstrated ability to apply critical thinking to identify patterns and trends;
Demonstrated ability to speak and write effectively at a level appropriate for the job including summarizing data and presenting results;
Demonstrated skills in performing regulatory and industry research relevant to functional responsibility;
Knowledge of medical records, medical terminology, Medicare guidelines, principles of ICD-9/ICD-10 and CPT coding;
Demonstrated skills navigating in an electronic medical record environment;
Demonstrated skills in Microsoft Office, databases and spreadsheets.

#LI-RL1 ~LI~


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Senior Clinical Appeals RN - New Hyde Park, NY - Veteran's Welcome

If you're looking for a better place to use your passion and your desire to drive change, this is the place to be.

It's an opportunity to do your life's best work.(sm) This is an office based role located in New Hyde Park, NY.

Primary Responsibilities: Coordinates appeals process Sorts, reviews and evaluates cases denied by all payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes Monitors inpatient denials and assists patients and physicians with management of the appeals process Writes first, second and third level insurance appeal letters Reviews and coordinates utilization issues concurrently and retrospectively related to denials from all payors Maintains data tracking systems and identifies Utilization trends Serves as a resource to all hospital staff related to Utilization Management issues Promotes staff development and education Assesses and monitors of quality issues, and follows-up with Quality Management 3 years of recent clinical experience Attends committee and staff meetings, as required Performs related duties as required Required Qualifications: Current license to practice as a Registered Professional Nurse in New York State 3 years recent/current clinical experience in the acute care setting Keep abreast of all changes in policies and procedures relating to Utilization Management and Case Management BSN degree Proficient in Microsoft office Preferred Qualifications: 1 years Case Management Experience Hospital-based experience writing appeals to refute clinical denials 1 years of clinical experience including, utilization management, discharge planning; third party payment systems; and appeals and denial processes Medical Coding or CDI experience Health care isn't just changing.

It's growing more complex every day. ICD10 replaces ICD9. Affordable Care adds new challenges and financial constraints.

Where does it all lead? Hospitals and health care organizations continue to adapt, and we are a vital part of their evolution. And that's what fueled these exciting new opportunities.

Optum360 is a dynamic new partnership formed by Dignity Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage all our resources to bring financial clarity and a full suite of revenue management services to health care providers nationwide. If you're looking for a better place to use your passion and your desire to drive change, this is the place to be.

It's an opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace.

Candidates are required to pass a drug test before beginning employment. Job Keywords: New York, NY, New Hyde Park, utilization management, case management, ICD 10, appeals, Quality



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Clinical Coordinator Appeals

Job Description

The Clinical Coordinator Appeals is responsible for investigating, documenting and responding to appeals requests. This position has no direct reports.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Process Medicare Part D or commercial appeal requests, ensuring that requests are correctly categorized as appeals and all deadlines are met
  • Create explanations of coverage for providers and generate an appeal entry in clinical processing system
  • Create case files for denied Medicare Part D appeals and forward to third party administrator for review
  • Receive and ensure timely processing of requests for Medicare Part D appeal case files
  • Process Medicare Part D second level appeals and respond with effectuation notices if necessary
  • Identify when company is and is not delegated to process commercial appeals and communicate appropriate course of action to providers
  • Submit commercial appeals to independent review entities for determinations
  • Inform members of appeal determinations via both verbal communication and appropriate written notification
  • Maintain list of commercial clients that have delegated appeals processing to company
  • Track Medicare Part D and commercial appeals for auditing
  • Prepare quarterly appeal reports
  • Other duties as assigned

REQUIREMENTS:

  • High school diploma or GED
  • Proficient in Microsoft Office and industry related software programs

  • Ability to work extended hours, weekends, and holidays pursuant with industry demands

  • Ability to independently identify, research and resolve issues

  • Effective verbal and written communication skills

  • A decisive individual who possesses a detail oriented perspective

  • Sound technical skills, analytical ability, good judgment, and strong operational focus

  • Ability to work with peers in a team effort

  • Demonstrated ability to manage multiple priorities and deadlines

  • A well-organized and self-directed individual who is able to work with minimal amount of supervision

  • Capability to efficiently complete tasks in a fast paced environment

PREFERRED QUALIFICATIONS:

  • Bachelor’s degree
  • Pharmacy technician experience
  • Certified, Licensed, or Registered Pharmacy Technician

  • Medicare part D knowledge
  • Previous experience in appeals processing

WORK ENVIRONMENT:

Includes a call center environment, with exposure to excessive noise with minimal exposure to adverse environmental issues.

PHYSICAL REQUIREMENTS:

Ability to sit for prolonged periods of time

  • Pre-employment drug screening and background checks are required. The company offers a competitive salary and benefits package. EOE. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, disability or veteran status.
    • EnvisionRxOptions is committed to maintaining a productive, drug-free workplace that keeps employees and customers safe from harm.

Company Description

EnvisionRx, with a commitment to providing transparency and disclosure to the Pharmacy Benefit Management (PBM) marketplace, provides full service, integrated PBM services, including network-pharmacy claims processing, mail order, benefit design consultation, drug utilization review, formulary management, and other related services. If you are interested in becoming part of a team-oriented, fast-growing company we encourage you to consider a satisfying career at EnvisionRx.

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