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Position: Clinical Appeals Specialist
Location: Reston VA #REMOTE
Duration: Long term
Job Description :
Licenses/Certifications :
ESSENTIAL FUNCTIONS :
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.
Thanks & Regards
LAXMAN
KMM Technologies Inc.
CMMI Level 2 ISO 9001 ISO 20000 ISO 27000 Certified
WOSB SBA 8(A) MDOT MBE & NMSDC MBE
Tel: (240) Email:
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