CHS Utilization and Appeals Manager
$110,000–$110,000 year
On-siteMelville, New York, United States
Job Summary
Conduct clinical reviews and manage appeals according to industry guidelines, researching denials to identify reasons and contributing factors. Submit initial and appeal reviews within contractual timeframes, handling queries from payors for additional documentation. Collaborate with physicians and the physician advisor on clinical discussions, communicating patient status changes to the Medical Case Conference. Act as a liaison for regulatory and managed care requirements, reporting findings on compliance issues to department leadership. Complete data tracking tools and participate in monthly meetings while maintaining strict patient confidentiality and security standards.
Required Qualifications
- current New York State, R.N. License
- BSN Bachelor of Science in Nursing
- Minimum 5+ years of relevant clinical medical-surgical or specialty experience
- Experienced appeals writer
- Care Management experience in an acute hospital or related managed care setting
- Sound knowledge and skill in the use of personal computer and software for word processing and spreadsheet
- Experience with EPIC, Midas, Star and other hospital software
- Ability to effectively communicate with all levels of hospital staff in a verbal and written manner
- demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction
- courteous and professional demeanor
- team spirit
- ability to work in a collaborative, effective manner
- clinical expertise/reference for specialty services
- aptitude and skill in applying sound financial and reimbursement principles to all utilization and appeal functions and reporting
- Ability to utilize critical thinking
- apply sound clinical judgment and assessment skills for decision-making
- Expert knowledge of evidence based guidelines
- Maintains knowledge of requirements by third party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits and medical necessity guidelines
- Knowledge of managed care and the current standards and trends of patient care, best practices, management tools
Desired Qualifications
- Graduate of an accredited Nursing School or College
- Health
- Knowledge of Federal, State and PRO regulations
- Required to pursue ongoing education, certification and self development to remain current with industry standards and business objectives related to Utilization and Care Management as appropriate
- Knowledge of managed care and the current standards and trends of patient care, best practices, management tools
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