POSITION SUMMARY

Reports to Senior compliance manager. Responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of member and provider appeals and grievances in a timely and culturally sensitive manner and as per Health Plan contractual agreements. Responsible for the timely reviewing of denial letter language to ensure compliance with regulatory agencies. Responsible for performing retrospective medical claims review in a timely manner ensuring that approved standardized criteria are used to review for medical necessity.

RESPONSIBILITIES-DUTIES

Appeals & Grievances:

• Process all Appeals and Grievances (G&A) in accordance with AMM policies and procedures
• If IPA is delegated for Grievance Process, the Health Plan will be notified within 24 hours of receipt of the grievance and will provide written notification to the member within 5 days. When not delegated for this process, the complaint/grievance and requested records will be forwarded to the Health Plan in a timely manner
• Work with the Quality Management Committee and Director to review and analyze appeals and grievance trends and recommend corrective action as necessary
• Logs and track processes for both appeals and grievances categorizing according to type for reporting and trending purposes (ie referral delay or denial, claims, provider access, cultural and linguistic issue)
• Contact members, providers, and other relevant individuals to gather information and communicate disposition of cases
• Conduct pertinent research in order to evaluate, respond to, and to close appeals in accordance with all established regulatory guidelines
• Immediately follow-up by contacting members via telephone on all urgent or grievous complaints and enlist Medical Director intervention if appropriate
• A Quality Management Notice will be completed on all complaints. Member will receive an acknowledgement of receipt of complaint within 3 days. Resolution and communication will be completed within 30 days
• Ensure timely G&A reporting to regulatory agencies
• Maintain and update on an annual basis or as necessary A&G policies and procedures, member correspondence etc. consistent with regulatory changes
• Assist with processing Prior Authorizations when items listed above are low in volume

Retrospective Claims Review:

• Receives pending claims with attached medical records from Claims Department
• Performs medical necessity review utilizing appropriate, approved, and standardized clinical coverage guidelines ie CMS/Medi-Cal Criteria, Health Plan Medical Policies or InterQual criteria
• Requests additional medical records if necessary and instructs/updates Claims Department
• Forwards to Medical Director for review if Nurse unable to make a determination or determines that a denial is appropriate
• If Claim can be approved after medical necessity review is complete then a referral is entered into the Ezcap authorization system and the Claims Department is notified to adjudicate the claim
• Retrospective claims review will be completed in a timely manner and in accordance with regulatory compliance guidelines
• If after the Medical Director review, denial is recommended the Nurse with the help from the Coordinator will generate a denial letter and will cite the appropriate criteria that was used as the basis for the denial and include appeal instructions

Denial Language Reviewer:

• Coordinator runs report off of Audit Manager which provides list of all referrals that have been denied
• Coordinator identifies the appropriate denial letter template based on the line of business eg Medicare/Medi-Cal or Commercial and forwards to the Nurse Reviewer for denial language and criteria
• Nurse reviews and update all denial letters in a timely manner citing criteria used as basis for the denial in order to ensure compliance with regulatory guidelines

• Nurse/Coordinator reviews all denial letters to ensure that the language is in layman’s terms and uses on-line tools (ie Goggle or https://www.uhcdocscrub.com/login.php) that translate medical terminology into denial language so it is understandable to members
• Letters are sent back to Coordinator who mails letters to members and enters the letters in Cerecons notifying Providers (PCP) of the denial determination

EDUCATION & EXPERIENCE REQUIREMENTS

• Have deep compassion for patients and the care they receive
• Licensed personnel (LVN) with one to three years of UM experience in an IPA/PMG or HMO setting
• Prior experience in Grievance/Appeals, medical claims review preferred
• Experience with computer and software programs (Microsoft Word, Excel, etc) and use of information technology to analyze data
• Advanced oral and written communication ability required
• Planning and organization skills required
• Experience in applying Interqual IP Guidelines, Health Plan Guidelines and CPGs to UR requests, where applicable.
• Strong clinical judgment necessary to interpret and follow medical guidelines
• Demonstrated skills in resolving complex issues
• Be courteous and promote professionalism
• Be flexible and adaptable
• Promotes organizational goals
• Maintains the highest degree of professionalism and credibility at all times
• Maintains confidentiality and follow HIPAA policies

Job Type: Full-time

Pay: $30.00 - $50.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Experience:

• Utilization management: 3 years (Preferred)

License/Certification:

• LVN (Preferred)

Work Location: In person