Denials Specialist

Position Overview:

CBH is a dynamic organization dedicated to providing access to high-quality, accountable care to improve the health and mental wellness of our members. The mission of CBH Denials Specialist is to oversee all aspects of the denial process for Clinical Management and Medical Affairs. This includes daily review of all insufficient denial notices. The Denials Specialist will also participate in grievance hearings as the clinical representative.  

Essential Functions:

• Be knowledgeable about behavioral health care services, system partners, service continuum, and established medical necessity criteria.
• Serve as the subject matter expert on all aspects of the denial process at CBH including policies, protocols, NCQA and HealthChoices regulations.
• Update the annual Denial Training and ensure that all required staff have completed the training.
• Serve as the clinical representative in all grievance hearings.
• Review all insufficient and denial notices and ensure accuracy prior to their release.
• Complete monthly timeliness and system control reports.
• Review monthly denial audits and follow up when indicated.
• Prepare all denial documents for NCQA review.
• Maintain documentation in CBH’s electronic system consistent with agency and industry standards.
• Respond to correspondence within 24 hours, or sooner if necessary.
• Work collaboratively with team members including assisting with the training of newly hired employees as requested, covering work when peers are out of the office as assigned and finding coverage when absent.
• Attend all meetings as assigned and actively prepare for and participate in supervision.
• Assist with special projections and all other duties as assigned.

Position Requirements: 

• Education: Master’s degree in Social Work or related field
• PA Child Abuse Clearance and Criminal Background Check required.
• Relevant Work Experience: Experience in a managed care setting preferred, as well as experience with regulatory agencies.

Skills:

• Excellent verbal and written communication skills and ability to use them when communicating with internal and external stakeholders
• Excellent interpersonal and collaboration skills
• Proficient in MS Office
• Ability to work independently and as part of a team
• Excellent time management and prioritization skills and ability to multi-task
• Compliant with HIPAA regulations

CBH Requirements and Accommodations:

Philadelphia Residency Requirement:

The successful candidate must be a current Philadelphia resident or become a resident within six months of hire.

U.S. Authorization Requirement: 

CBH does not provide sponsorship for applicants requiring future work authorization. All candidates must be legally authorized to work in the United States without requiring sponsorship now or in the future.

Equal Employment Opportunity:  

We strive to promote and sustain a culture of diversity, inclusion, and belonging every day. CBH is an equal opportunity employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on all qualified individuals. This is without regard to race, ethnicity, creed, color, religion, national origin, age, sex/gender, marital status, gender identity, sexual orientation, gender identity or expression, disability, protected veteran status, genetic information or any other characteristic protected individual genetic information, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function by applicable federal, state, or local law.

Requesting Accommodation:

CBH is committed to providing equal employment opportunities for individuals with disabilities or religious observance, including reasonable accommodation when needed. If you are hired by CBH and require accommodation to perform the essential functions of your role, you will be asked to participate in our accommodation process. Accommodation made to facilitate the recruiting process is not a guarantee of future or continued accommodation once hired.

If you would like to be considered for employment opportunities with CBH and have accommodation needs for a disability or religious observance, please send us an email at CBH.Recruitment@Phila.gov