Health is the result of over a decade of dedicated visionary leaders and innovative organizations challenging the status quo for PAC management solutions. We do healthcare differently and we are changing healthcare one patient at a time. How might you ask? By hiring talented clinicians, engineers, analysts, and healthcare leaders to create and utilize cutting edge technology to provide the patient with the best level of care for the right amount of time.
Why Is This Role Critical?
The Appeals Coordinator plays an integral role in optimizing the patient's recovery journey by providing a comprehensive review of a member's clinical information in response to an appeal from the Quality Improvement Organization (QIO) or the Health Plan. The Appeals Coordinator is responsible for writing the DENC (Detailed Explanation of Non-Coverage) or preparing an appeal response package once an appeal has been filed. The Appeals Coordinator is responsible for processing and documenting the appeal based on CMS regulatory guidelines and nH policies. The Appeals Coordinator is also responsible for processing and documenting appeal determinations and notifications. They will also collaborate with physicians, clinical staff, management and financial functions to process an appeal or determination in a timely manner and within compliance of the regulatory guidelines and policies.
What you will be accountable for.
Owns assigned appeal requests or determination notifications that are received via fax, phone, or email
Processes appeal or notification in accordance to CMS and nH guidelines and compliance policies
Creates DENC letter as part of appeal process, by reviewing and documenting member clinical information and sends letter to member, QIO entity, and/or Health Plan representative
Reviews NOMNC for validity prior to processing appeal request
Sends review to MD for rescinding NOMNC when necessary, following nH processes
Coordinates and communicates with care coordinators, physicians, health plan representatives, QIO entity, and providers regarding the appeal or determination and provides education as needed
Processes Health Plan appeal notifications and determinations as needed
May assist with completing pre-service authorization requests to assist pre-service team as needed
Participates in after-hours on-call rotation and weekend rotation for processing pre-service authorizations and appeals
Follows processes for documentation of the appeal in the nH Coordinate
What you will need to be successful
Current Licensure as a Physical, Occupational, or Speech Therapist (PT, OT, or ST), or Registered Nurse (RN)
Current active unrestricted clinical license required
Bachelor's degree in healthcare-related field or equivalent work experience
At least two years' recent experience in case-management or utilization management.
3-5 years clinical experience in a relevant discipline (i.e., RN, OT, PT, ST).
ICD-10 and InterQual experience a plus
Strong technical/computer skills
Excellent documentation skills required.
Self-starter with the ability to prioritize daily work load.
Strong interpersonal and communication skills (both verbal and written).
Understanding of market variability related to the denial process, specific contractual obligations and CMS regulations
Ability to travel if business needs required and ability to establish a home office work location if needed.
Excellent communication skills to complete the role telephonically.
Experience with Microsoft Excel and Word.
Interested internal candidates must be approved by current clinical manager as a high performing professional requiring minimal direct supervision (as evidenced by chart reviews, interrater reliability results and direct observation.)
The nice to haves
Multiple state nursing licenses (if RN)
ICD-9 and InterQual experience a plus.
CMS knowledge preferred.
Experience with appeals processing.
Current knowledge of multiple nH contracts.
Health is a pioneer in post-acute care and care transitions with a combined, unprecedented 18-years of experience that uniquely positions us to manage patients, improve clinical and financial outcomes, and share risk with payors and providers. As a Cardinal Health company, we provide clinical support alongside scalable technology and advisory solutions that empower health systems, health plans, and post-acute providers to navigate care episodes across the continuum, with the goal of reducing waste and improving patient outcomes.
We care about the people we serve.
We care about each other.
We care about our communities.
We embrace innovation.
We like simple.
Health is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Cardinal Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.