Nashville, United States
over 1 year ago
Conducts detailed appeal investigation of all supporting documents and systems to determine if the appeal should be upheld or overturned based on all available facts. Proactively communicated with appellants, leadership team, providers and the original case manager to resolve investigation issues, resolve issues and communicate decisions/rationale for denial/approval.
Retrieve assigned cases from queue and based on analysis of issues determine appropriate classification Validate all assigned cases; review appeal documents, correct appeal types, timeframes and what is being appeals Assign priority and internal due date based on various regulations which dictate the compliance timeframes. This is a key step as incorrect classification will result in non-compliant cases Independently conduct thorough review of all new member and provider correspondence by analyzing all the issues presented to determine appropriate classification Employee is responsible for tracking internal due dates and timeframes so that the Compliance timeframes are met Classify document all actions taken during review for auditing and reporting purposes Monitor daily reports, as well as make necessary follow-up calls to internal and external entities to all information is received or before the applicable timeframe Assist the Manager/Supervisor in identifying root cause issues related to appeals Regular attendance is an essential function of the job. Performs other duties as assigned or required Requires the ability to consistently apply appropriate administrative and regulatory criteria for reviewing and making decisions on all non-clinical appeals and validating the accuracy of all received information
Requires effective communication abilities (written and verbal) when documenting actions and communications with Members, Providers, Medical Director and appeals leadership. The role works closely with the multiple other roles and requires the ability to communicate status variances Responsible for maintaining and prioritizing work load to support appeal timeliness and communicate risks, concerns or opportunities to leadership related to their work load