• Nurse Appeals is responsible for supporting the development and implementation of quality improvement interventions and audits; investigates and processes medical necessity appeals requests from members and providers. Primary duties may include, but are not limited to: Conducts investigations and reviews of member and provider medical necessity appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
• Daily Responsibilities: Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Review clinical information for all appeals including Speech, Occupational, and Physical Therapy cases utilizing nationally recognized criteria to determine medical necessity of services requested. Gather, analyze and report verbal and written information regarding member and provider clinical appeals, and Therapy including information follow up's.
Denial Clinical Compliance Coordinator: October 7, 2013 - June 2016
• Audit and revise all denial and appeal letters for Superior Health Plan locations.
• Ensure letters are compliant with NCQA standards.
• Coordinate with Manager of Preauthorization & Referrals on training needs.
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.
• Act as liaison with the Quality Department to maintain current knowledge of NCQA and State regulations within the Medical Management Department.
Took and recorded patients' temperature, pulse and blood pressure.
thorough supervision for day-to-day operations of facility in accordance with set policies and guidelines.
In my current position with Centene I have worked on the "Letter Comittee" which helps create and reconstruct a template that helps the Appeals department to create our letters to our members.
Appeals New Hire Mentorship/Training: Appeal Mentor is to be a first line of resource when assistance is needed after attempted to follow the appeal training manual and work processes. While in the mentorship phase it is required that the new nurse/therapist work closely.
Back Up Therapy Nurse: Trained to process Therapy (Speech, Physical, and Occupational Therapy) Appeal Cases
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