Nurse, Clinical Appeals

The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request.

35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates. 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights. 25% Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accredidation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS. 5% Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.