Description:
Coventry Health Care of the Carolinas, Inc. has an immediate opening for a Clinical Appeals Nurse in our Morrisville, NC office.
GENERAL SUMMARY
Responsible for coordinating grievance appeals activity and ensuring compliance with State and Federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Responsible for reviewing correspondence from members requesting to file a grievance. Coordinates a response to the member in compliance with all specified timeframes.
- Responsible for coordinating the collection of all information and the presentation to the Medical Director/Appeals Committee.
- Handles complex clinical appeals such as transplants.
- Works closely with Medical Directors on clinical issues to ensure comprehensive appeal investigations.
- Coordinates outside physician clinical reviews.
- Responsible for ensuring that all timeframes throughout the appeals process are met.
- Researches member information in response to difficult inquiries, including but not limited to authorizations, payments, denials, coordination of benefits.
- Works closely with Health Services contact in obtaining clinical information of appeals for denial of services.
- Assesses, investigates, and resolves difficult issues to achieve member satisfaction.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Clinical licensure required based on clinical sector supported.
- General Appeals requires current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC) , licensed psycholgist, or Registered Nurse (RH).
- Bachelor's degree or equivalent experience.
- Experience in processing and working with all types of products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
- Previous (1-2 years) customer service experience preferred.
- Medical terminology and computer skills required.
- Experience processing and working with appeals preferred.
- Effective communication skills required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Morrisville, NC, US
Other Locations: ,
Organization: 28000 - Coventry Health Care of the Carolinas, Inc
Schedule: Full-time
Job Posting: 2013-06-20 00:00:00.0
Job ID: 1312086
Coventry Health Care of the Carolinas, Inc. has an immediate opening for a Clinical Appeals Nurse in our Morrisville, NC office.
GENERAL SUMMARY
Responsible for coordinating grievance appeals activity and ensuring compliance with State and Federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Responsible for reviewing correspondence from members requesting to file a grievance. Coordinates a response to the member in compliance with all specified timeframes.
- Responsible for coordinating the collection of all information and the presentation to the Medical Director/Appeals Committee.
- Handles complex clinical appeals such as transplants.
- Works closely with Medical Directors on clinical issues to ensure comprehensive appeal investigations.
- Coordinates outside physician clinical reviews.
- Responsible for ensuring that all timeframes throughout the appeals process are met.
- Researches member information in response to difficult inquiries, including but not limited to authorizations, payments, denials, coordination of benefits.
- Works closely with Health Services contact in obtaining clinical information of appeals for denial of services.
- Assesses, investigates, and resolves difficult issues to achieve member satisfaction.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Clinical licensure required based on clinical sector supported.
- General Appeals requires current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC) , licensed psycholgist, or Registered Nurse (RH).
- Bachelor's degree or equivalent experience.
- Experience in processing and working with all types of products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
- Previous (1-2 years) customer service experience preferred.
- Medical terminology and computer skills required.
- Experience processing and working with appeals preferred.
- Effective communication skills required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Morrisville, NC, US
Other Locations: ,
Organization: 28000 - Coventry Health Care of the Carolinas, Inc
Schedule: Full-time
Job Posting: 2013-06-20 00:00:00.0
Job ID: 1312086