Clinical Reviewer, Grievance & Appeals

Summary of Position

Perform clinical and administrative reviews within the Grievance and Appeals department, ensuring accurate administration of benefits, execution of clinical policy, timely access to appropriate levels of care and provision of payment for services that have already been rendered. Support the corporate and departmental goals and objectives.

Responsibilities:

* Prepare and present clinical summations/recommendations to the Medical Director or Pharmacist, or Independent Review Organization in accordance with state and federal regulations, NCQA requirements, and internal policy for final case determination in accordance with regulation and department policy.
* Research evidence-based guidelines, medical protocols, member benefit packages, provider networks, and on-line resources to review and investigate member and provider requests; determine appropriate utilization of benefits and/or claim adjudication. Consider quality initiatives and regulatory requirements as part of all case assessments.
* Under the direction of the leadership, is responsible for the execution of efficient departmental processes designed to manage utilization within the benefit plan. Responsible for the review of grievance and appeal cases referred for clinical and administrative pre-service, concurrent, and post-service appeal determinations; expedited and standard.
* Act as a clinical coordinator collaborating with members, providers, and facilities to evaluate member needs within the appropriate clinical setting, and as a clinical resource to the non-clinical Appeals staff.
* Enter and maintain documentation in the appropriate workflow tools meeting defined timeframes and performance standards (decision, notification, and effectuation).
* Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, NCQA and business standards. Effectively communicate verbally and in writing all decisions in an understandable, effective, timely and professional manner.
* Maintain an understanding of utilization management/grievance and appeals program objectives and design, implementation, management, monitoring, and reporting.
* Track and trend outcomes, analyzes data, and report on these to the Supervisor/Manager as required.
* Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager; report any quality of care or services issues or serious adverse events identified through the appeals process to the appropriate staff for investigation and processing.
* Assist with processing Department of Insurance Complaints related to medical necessity determinations; review and decide if a denied service or claim should be reversed or consult with the Medical Director in the decision-making process.
* Regular attendance is an essential function of the job. Perform other duties as assigned or required.