Job Description

Reach me on Tel: (240) Email:

Position: Clinical Appeals Specialist

Location: Reston VA #REMOTE

Duration: Long term

Job Description :

• 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.
• Education Level: High School Diploma
• Preferred: BSN/MSN Degree
• Experience: 2 years medicalsurgical or similar clinical experience OR 3 years experience in mental health psychiatric setting.
• Required: Clinical Records Review HIPPA
• 2 years experience in Medical Review Utilization Management or Case Management at CareFirst BlueCross BlueShield or similar Managed Care organization or hospital preferred.
• Knowledge and understanding of medical terminology. Advanced
• Demonstrated knowledge of regulatory and accreditation requirements understanding of appeals process and utilization management and systems software used in processing appeals. Proficient
• Excellent verbal and written communication skills strong listening skills critical thinking and analytical skills problem solving skills ability to set priorities and multitask Proficient
• Ability to effectively communicate and provide positive customer service to every internal and external customer. Advanced
• Knowledge of Microsoft Office programs. Proficient
• Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions. Proficient

Licenses/Certifications :

• RN Registered Nurse State Licensure And/or Compact State Licensure OR
• CCM Certified Case Manager OR
• LNCC Legal Nurse Consultant Certified

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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