Appeals & Grievances RN (Compact Licensed)

About the role

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Responsibilities

• Consider, review, and evaluate cases in compliance with state and federally mandated turn-around-times and process requirements.
• Ensure that all necessary clinical information is available to allow for a full and fair review.
• Outreach as necessary to provider/provider staff for clarification or additional information needed.
• Prepare claims and case summary for MD review and appropriate decision.
• Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements.
• Access and review various resources to support denial or overturn denial.
• Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention, and Continuity of Care.
• Work proactively to expedite the care process.
• Identify priorities and necessary processes to triage and deliver work.
• Empower members to manage and improve their health, wellness, safety, adaptation, and self-care.
• Assess and interpret member needs and identify appropriate, cost-effective solutions.
• Identify and remediate gaps or delays in care/services.
• Advocate for treatment plans that are appropriate and cost-effective.
• Work with low-income/vulnerable populations to ensure access to care and address unmet needs.
• Gather and evaluate clinical information to assess and expedite referrals within the healthcare system, including consideration of alternate levels of care and services.
• Facilitate timely and appropriate care and effective discharge planning.
• Work collaboratively across the healthcare spectrum to improve quality of care.
• Leverage experience/expertise to observe performance and suggest improvement initiatives.
• Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes.
• Ensure individual and team performance meets or exceeds the performance competencies and metrics.
• Contribute actively and effectively to team discussions.
• Share knowledge and expertise, willingly and collaboratively.
• Provide outstanding customer service, internally and externally.
• Follow and maintain compliance with regulatory agency requirements.

Requirements

• Current unencumbered Compact RN license.
• Minimum of 5+ years of acute clinical experience.
• Minimum 2 years experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.).
• 2+ years of appeals and grievance experience in a managed care environment.
• Strong knowledge of utilization management processes and industry best practice.
• In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual, etc.).
• Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care, and home health care.
• HMO and risk contracting experience preferred.
• In-depth knowledge of current standard of medical practices and insurance benefit structures.
• Proficiency in Microsoft Office.

Qualifications

• Ability to translate member needs and care gaps into a comprehensive member-centered plan of care.
• Ability to collaborate with others, exercising sensitivity and discretion as needed.
• Strong understanding of managed care environment with population management as a key strategy.
• Strong understanding of the community resource network for supporting at-risk member needs.
• Ability to collect, stage, and analyze data to identify gaps and prioritize interventions.
• Ability to work under pressure while managing competing demands and deadlines.
• Well organized with meticulous attention to detail.
• Strong sense of ownership, urgency, and drive.
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.
• The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.
• Excellent analytical-thinking/problem-solving skills.
• The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads.

Physical Requirements

• Must be able to sit in a chair for extended periods of time.
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word.
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices.
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse.
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types.
• Must be able to fluently communicate both verbally and in writing using the English language.

Schedule

Expected hours of work: Friday 8am – 5 pm EST; with ability to adjust to Client schedules as needed.

Travel may be required, as needed by Client.

Time Zone: Eastern or Central.

Pay

Salary Range: $70,000 - $100,000.