Appeals Processing Analyst

Position Summary:

Responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources.

Medical necessity reviews may include: planned elective services, surgical and diagnostic procedures, durable medical equipment and out of network services.

Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.

Essential Duties and Responsibilities:


* Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.


* Uses an established set of criteria to evaluates and authorize the medical necessity of services.


* Provide notification of decisions in accordance with compliance guidelines.


* Coordinate with Medical Directors when services do not meet criteria or require additional review.


* Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.


* Works with management team to achieve operational objectives and financial goals.


* Supports teams across UM Department as needed.


* Active participation and completion of all required trainings.


* Maintain Required Licensures.


* Adherence to regulatory and departmental timeframes for review of requests


* Meet/exceed department Turn Around time, daily established productivity goals, and service levels


* Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards;


* Professional demeanor and the ability to work effectively within a team or independently;


* Flexible with the ability to shift priorities when required


* Other duties as required

Qualifications:


* Current Licensed Practical Nurse LPN or Licensed Vocational Nurse LVN or RN License


* Minimum 2-3 years clinical experience.



* Experience in regulated managed care setting preferred


* Strong Customer orientation


* Strong organizational, planning, and communication skills


* Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus


* Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.


* Excellent time management skills

Knowledge, Skills, Abilities Required:


* Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member


* Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments


* Able to work in a dynamic, fast-paced team environment and to promote team concepts


* Excellent typing skills.
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