Clinical Appeals Coordinator

UPMC Health Plan has an exciting opportunity for a Clinical Appeals Coordinator position in the Provider Disputes CGA department. This is a full-time hybrid position working Monday through Friday daylight hours, with occasional on call shifts. This position is based in the Pittsburgh area. While you'll primarily work remotely, you'll come into the office occasionally depending on departmental needs.

This position coordinates and completes all medically necessary provider appeals. The functions include reviewing cases for medical necessity, coordination with the Medical Directors and preparing regulatory submission packets based on medical necessity to CMS for Medicare provider appeals. The provider clinical review is for all levels of services and all lines of business.

Responsibilities:

• Review, investigate and complete appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes.
• Work closely with Special Investigations Unit (SIU, Network Development, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, Benefit Configuration, Compliance, Enrollment, Pharmacy Services, Reimbursement and Coding departments to ensure review processes are understood and meet Health Plan strategy for appropriateness of provider reimbursement as well as quality of care and services.
• Manage escalated member and provider issues as required.
• Perform clinical education and mentor staff members as necessary.
• Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review.
• Coordinates timely case review by a Health Plan Medical Director.
• Review and approve administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc.
• Review and investigate appeals from providers where decisions by the health plan Special Investigation Unit audit process have impacted reimbursement.
• Determine uphold or overturn of decision.
• Create correspondence for review prior to finalizing-outreach to members and/or providers as needed to obtain and review additional clinical documentation.
• Interpret Medical Director notes and summarize into correspondence for member, provider and/or facility.
• Track and trend appeals related to medical necessity, coding issues and other administrative reasons.
• Report trends to management and Network Development for improvement opportunities and provider education.
• Prepare comprehensive Independent Review Entity Packets, including clinical justification of the Medical Director's decision which includes all applicable points from the specific policy, Evidence of Coverage statement and/or documentation submitted to which the decision pertains.
• Prepare physician consultant review packets for designated specialized services (i.e. Private Duty Nursing outline case and peer review needs
• Respond to members and/or providers in writing with the results of appeal review in accordance with Complaints and Grievances Department standards and all applicable regulatory requirements.
• Outreach to providers as appropriate to communicate decision.
• Assist in the creation, enhancement and implementation of process workflows for the Complaints and Grievances Department.
• Assist with identifying continuing education needs and opportunities; maintain continuing education and appropriate CEUS required for RN licensure.
• Registered nurse with a minimum of two years direct patient care experience required.
• Two years of Health Insurance experience as a Registered Nurse in a Utilization Management/Medical Management role strongly preferred.
• BSN preferred.
• Experience with accountability for regulatory compliance for entities such as NCQA, CMS, Department of Public Welfare, Department of Health and Pennsylvania Insurance Department preferred.
• Excellent verbal and written communications skills required.
• Direct experience with physicians or facilities regarding health insurance reviews and reimbursement preferred.
• Working knowledge of insurance benefit packages preferred.
• The ability to work in a fast-paced insurance environment and to handle multiple priorities/projects in a professional manner required.
• Working knowledge of ICD-9/ICD-10 and CPT classifications and coding of diagnoses and procedures preferred.
• Proficiency in computer skills required.
• Ability to collaborate effectively with physicians and other health care professionals.
• Strong organizational and problem-solving skills with ability to make decisions independently.

Licensure, Certifications, and Clearances:

• Registered Nurse (RN
• Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran