Clinical Appeals Coordinator

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🕒 July 2

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • 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

• 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 for 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 • Contribute to 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); OR 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, and three years of clinical experience • Three years’ experience with clinical claims processing and review • Three years’ experience working with appeals and grievances • Two 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 drive improved efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office • Bachelor of Science in Nursing preferred • Medical Management experience preferred

🏖️ Benefits

• Career of life-long learning and continuous improvement • Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions