Peak Health
51 - 200 employees
⚕️ Healthcare Insurance
🤝 Non-profit
Healthcare Insurance • Non-profit
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
🔥 0 minutes ago
📊 Check your resume score for this job
Improve your chances of getting an interview by checking your resume score before you apply.
Peak Health
51 - 200 employees
⚕️ Healthcare Insurance
🤝 Non-profit
Healthcare Insurance • Non-profit
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 both members and providers • Conduct and lead investigations and reviews for member and provider medical necessity appeals • Review the medical record of denied services for medical necessity • Provide a summary of case for the medical director, and other partners in the health plan care team • Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements • Document and log case information for the appeal • Generate the written response to the member or provider • Serve as a subject matter expert for appeals and grievances
🎯 Requirements
• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license • 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 enhanced Nurse Licensure Compact (eNLC) • Three (3) years of clinical experience • 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 • Bachelor of Science in Nursing (preferred) • Medical Management experience (preferred)
🏖️ Benefits
• Standard office environment
Apply NowSimilar Jobs
🔥 1 hour ago
Clinical Appeals Coordinator in a health plan's medical management team. Investigating and processing medical necessity requests from members and providers while ensuring compliance with regulations.
🔥 21 hours ago
Clinical Coordinator responsible for securing and maintaining clinical sites for nursing programs. Supporting curriculum delivery and evaluating student clinical experiences at Rasmussen University.
🕒 June 25
Working at USC
10,000+ employees
Charge Capture Coordinator responsible for charge capture in clinical settings, ensuring accurate billing and compliance. Collaborating with healthcare teams and managing charge-related documentation tasks.
🕒 June 25
Charge Capture Coordinator at Keck Medicine of USC responsible for charge capture and billing accuracy. Ensuring completeness and compliance of clinical documentation in revenue producing departments.
🕒 June 25
Clinical Review Coordinator conducting case reviews and quality assurance activities in healthcare at Commence. Requires RN or LPN license, located in Las Vegas, NV for remote work.
