Utilization Review Nurse - Appeals

Cigna Medicare Part C Appeals Reviewer: Appeals Processing Analyst
We will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.

The Case Management Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan.

These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs.

The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.
This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm CST - Monday through Friday with occasional weekend and holiday coverage.

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.


* Communica...