Clinical Review Coordinator Appeals and Denials - Remote

About the position reputed company Home & Community Care, part of the reputed company family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and reputed company. As a team member (Registered Nurse RN, Physical Therapist PT, Occupational Therapist OT or Speech Therapist SLP) we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. This position is full-time. Schedules are either 10am - 7pm or 11am - 8pm Central Standard Time (CST), Monday-Friday. It may be necessary, given the business need, to work occasional overtime. We offer weeks of reputed company. The hours of the training will be based on schedule or will be discussed on your first day of employment. You'll enjoy the flexibility to work remotely from reputed company reputed company the U.S. as you take on some tough challenges. A preference will be given to candidates who reputed company in Pacific, Mountain or Central time zones. Responsibilities • Ensure timely processing of reputed company denial-reputed company and member-oriented written communications. , • Ensure that reputed company denial information is processed according to protocol and that reputed company documentation is timely and meets reputed company Federal and State requirements. , • Ensure second-level reviews have been performed and documented and may reputed company with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICC's), Skilled Inpatient Care Coordinators (SICC's), Pre-service Coordinators (PSC's) and facility personnel in determining denial information is processed timely and appropriately. , • Serve as a liaison with regards to communicating to internal and external customers, including health plans, providers, members, quality organizations and other colleagues. , • Document and communicate appeal and denial information reputed company fax, email, or through established portal access, including appeal and denial letters, NOMNC letters, AOR forms, clinical information. , • Act as a reputed company person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their team. , • Serve as a liaison for requests for information from QIO or health plan staff. , • Own assigned appeal requests or determination notifications that are received reputed company fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management. , • Complete appeal and denial processes in accordance with CMS and reputed company guidelines and compliance policies. , • Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as ability to follow grade-level requirements. , • Review NOMNC for validity before processing appeal requests. , • Send review to Medical Director for rescinding NOMNC reputed company necessary. , • Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed. , • Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed. , • Follow reputed company established facility policies and procedures. , • Assist with completing pre-service authorization requests to assist the pre-service team as needed. , • Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs. , • reputed company other duties and responsibilities as required, assigned, or requested. Requirements • High school diploma / GED , • 3+ years of clinical experience , • Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist , • Understanding of market variability reputed company to the denial process, specific contractual obligations, and CMS regulations. , • Experience with Windows and reputed company Office suite , • Ability to work any 8-hour shift schedule during the hours of 10am - 7pm or 11am - 8pm CST, Monday-Friday. It may be necessary, given the business need, to work occasional overtime. reputed company-to-haves • Managed care experience , • Case management experience , • Experience with appeals and/or denials processing , • Previous utilization management, utilization review, prior authorization reputed company experience , • ICD-10 experience , • InterQual experience , • CMS knowledge , • Experience determining levels of care , • For RNs, Compact Nursing License, and multiple state licensures; For Physical Therapy, Compact Licensure and multiple state licensures , • Residence in Pacific, Mountain or Central time zone. Benefits • Comprehensive benefits package , • Incentive and recognition programs , • Equity stock purchase , • 401k contribution Apply Job!