RN - Grievance and Appeals Clinical ReviewerMargate, FL, USA Req #461 Monday, April 1, 2024Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial Adverse Determinations or Organization Determinations that have been appealed. The Clinical Reviewer will handle expedited and standard requests and ensures that the appeals are processed in accordance with regulations, compliance standards and policy and procedures. Investigation and preparation of case narratives and statements of position based on clinical information, benefits, applicable regulations related to member or provider dispute of decisions. PRIMARY RESPONSIBILITIES:
Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; ensures all cases are completed in accordance with state and federal regulatory requirements including timelines.
Presents recommendations based on clinical review, criteria, and organizational policies
Communicates clearly and concisely, both verbally and in writing.
Analyze and complete written summaries on clinical cases.
EDUCATION AND EXPERIENCE:
Education: RN required.Required: RN license to practice. Preferred: 2 years of health care experience; preferably in a managed care environment in related area of responsibility, (i.e. utilization management, quality management, grievances, and appeals) Type of Experience Required: Strong analytical skills focusing on accuracy and attention to detail. Sound judgement. The ability to understand and apply medical criteria and product knowledge and experience. Excellent verbal and written communication skills. Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word Preferred: Specific Technical Skills: Outlook, Word, ExcelPreferred: Certifications/Licensure:Required: N/AKnowledge and Skills:
Working Knowledge of Health Care
Preferred:SCOPE INFORMATIONDirect Reports: n/aPHYSICAL REQUIREMENTS :The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required.Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.Other details
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Margate, FL, USA