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