Case Management Analyst

Job Requirements include, but not limited to:


* Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C


* Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.


* Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.


* Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied


* Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.


* Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director.


* Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response


* Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.


* Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)


* Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance


* Adhere to department workflows, desktop procedures, and policies.


* Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.


* Read Medicare guidance documents report and summarize required changes to all levels department management and staff.


* Support the implementation of new process as needed.


* Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers.

.


* Understand and investigate billing issues, claims and other plan benefit information.

.


* Assist with monitoring, inquiries, and audit activities as needed.


* Additional duties as assigned.

Qualifications


* Education: Licensed Practical Nurse (LPN) or Registered Nurse (RN)


* 3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service


* Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations.

Understanding of Local Coverage Determinations, National Coverage D...