Posted on Nov 17, 2018 by Affinity Executive Search
* Conduct investigations and reviews of member and provider grievances and appeals.
* Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
* Extrapolate and summarize medical information for medical director, consultants and other external review.
* Prepare recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
* Ensure that appeals and grievances are resolved timely to meet regulatory time frames.
* Document and log appeal/grievance information on relevant tracking systems and mainframe systems.
* Generate appropriate written correspondence to providers, members, and regulatory entities.
* Serve as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.
Ideal candidate will have
_REQUIRES 2-4 YEARS OR MORE OF EXPERIENCE IN A MANAGED CARE HEALTHCARE SETTING; OR ANY COMBINATION OF EDUCATION AND EXPERIENCE, WHICH WOULD PROVIDE AN EQUIVALENT BACKGROUND._
CURRENT ACTIVE UNRESTRICTED RN LICENSE to practice as a health professional within the scope of licensure IN THE STATE OF MINNESOTA required.
Appeals experience highly desired.
Utilization Management experience highly desired.
Medicaid experience preferred.
Managed Care experience preferred.
Critical Care (ER/ICU) experience very helpful.
Minimum of 5 years of direct-care experience strongly preferred.