Peak Health
51 - 200 employees
🏥 Healthcare
💼 Consulting
🛡️ Insurance
Healthcare • Consulting • Insurance
Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.
Clinical Appeals Coordinator
🕒 July 3
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Peak Health
51 - 200 employees
🏥 Healthcare
💼 Consulting
🛡️ Insurance
Healthcare • Consulting • Insurance
Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.
📋 Description
• Investigate and process medical necessity requests from members and providers • Conduct and lead investigations and reviews for member and provider medical necessity appeals • Review medical records of denied services for medical necessity, including relevant clinical notations for prospective reviews • Provide case summaries to the medical director and health plan care team partners • Ensure appeal timeframes meet enterprise, state, and federal standards and requirements • Document and log appeal case information • Generate written responses to members or providers • Serve as a subject matter expert for appeals and grievances • Commit to lifelong learning and continuous process improvement across Utilization Review
🎯 Requirements
• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC); alternatively, a current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the eNLC • Three (3) years of clinical experience required with the LPN pathway • Three (3) years’ experience with clinical claims processing and review • Three (3) years’ experience working with appeal and grievances • Two (2) years’ customer service experience • Working knowledge of InterQual and/or Milliman Care Guidelines • Knowledge of federal and state laws, NCQA, and industry regulations related to disease management, utilization management, case management, and discharge planning • Excellent written and oral communication • Problem-solving capabilities to improve efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office
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