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...
- Rate: Not Specified
- Location: Nashville, US-TN
- Type: Permanent
- Industry: Finance
- Recruiter: Cigna
- Contact: Recruiter Name
- Email: to view click here
- Reference: 24004790
- Posted: 2024-04-23 08:32:30 -
- View all Jobs from Cigna
More Jobs from Cigna
- Layout Inspector (Bloomington, MN)
- Field Tech I
- Senior Engineer - Water/Wastewater
- Clinical Account Executive - Express Scripts - Hybrid (Health Plans)
- Sales Operations Analyst (Retention)-Remote
- Sales Operations Associate Analyst (Retention)-Work from Home-1
- Sr. Principal, Consultant Relations - Evernorth Health Services - Hybrid
- RN Nurse Case Management Senior Analyst - Greater Mc Allen Texas/Upper Valley Area - Work Onsite at
- Manager, Provider Contract Network Management - AL/MS Market - Medicare Advantage
- New Business Consultant - Cigna Healthcare - Hybrid (Houston, TX)
- Medical Assistant - South East Region Float - Evernorth Care Group
- Business Finance Officer (Sr. Director)
- National Accounts - National Sales Advisor (NSA)
- Administrative Assistant, Digital Product
- Client Account Senior Analyst - Cigna Healthcare - Hybrid (Scottsdale, AZ)
- Client Account Senior Analyst - Cigna Healthcare - Hybrid (Houston, TX)
- Accountant, Financial Reporting - Evernorth - Hybrid
- Home Infusion Nurse, Part-time - Accredo - Hybrid - Delaware
- Sales New Business Development Manager, Hybrid
- Pharmacy Production Clerk- Accredo