WVU Medicine
10,000+ employees
⚕️ Healthcare Insurance
Healthcare Insurance
WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.
Clinical Appeals Coordinator
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🔥 0 minutes ago
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WVU Medicine
10,000+ employees
⚕️ Healthcare Insurance
Healthcare Insurance
WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.
📋 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 • Commit to a career of life-long learning and continuous improvement of processes related to Utilization Review
🎯 Requirements
• Current Registered Nurse license issued by the state • OR Current Licensed Practical Nurse license issued by the state AND 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
• Health insurance • Retirement plans • Paid time off • Flexible work arrangements • Professional development
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