RN Provider Appeals Coordinator (Hybrid) - Health Alliance Plan - 40 Hours Weekly - Day Shift

General Summary

Responsible for investigating Provider Appeal requests and Code Review inquiries for all Utilization Management divisions, including delegated entities. Summarize outcome of investigation for decision by Medical Director.

Principle Duties And Responsibilities

• Investigate and prepare case summary for Provider Appeal and Code Review inquiries based on network, product, medical criteria, regulatory requirements, and business rules.
• Present appeal case summary to Medical Directors for review and decision.
• Review and make decisions for appeal requests that include emergency and elective admissions, elective procedures, DME, Home Care, Hospice and Home Infusion.
• Review appeal request for appropriateness of setting, medical criteria, network, and business rules, while adhering to all department and regulatory requirements.
• Review and identify potential readmissions per HAP’s policy.

Education/Experience Required

• Nursing Diploma or equivalent.
• Bachelor's Degree in Health Care or related field preferred.
• Minimum of two (2) years of experience in clinical management of patients in an inpatient or ambulatory setting, or at least three (3) years of experience in Utilization Management or Case Management.
• Demonstrated knowledge of the InterQual® or Milliman Care Guidelines® criteria preferred.
• Knowledge of Medicare, Medicaid and NCQA guidelines and use of CMS website for research preferred.
• Knowledge of use of Microsoft Office Suite.
• Knowledge of ICD-10 and CPT coding, medical necessity criteria and medical terminology.
• Must work effectively with persons of varying position levels and diverse interests to reach consensus on resolution of problems.
• Excellent written and verbal communication skills.
• Must be able to interact professionally with physicians, members, and other internal and external customers.
• Able to prioritize and coordinate workflow.
• Able to manage multiple tasks simultaneously.
• Able to work independently with limited supervision.
• Must have excellent organizational skills.
• Must have excellent interpersonal and telephone skills.
• Able to make decisions and initiate appropriate actions based on analysis of data.
• Able to participate in problem identification and resolution with team members.
• Knowledge of inpatient and outpatient procedures and practices.
• Knowledge of NCQA, CMS, DOL, ERISA and other regulatory body rule preferred.
• Computer skills including Windows and Microsoft Word. Excel and Access preferred.

Additional Information

• Organization: HAP (Health Alliance Plan)
• Department: Medical Appeals Henry Ford Health
• Shift: Day Job
• Union Code: Not Applicable