New

Clinical Appeals Specialist

Ampcus, Inc
United States, Virginia, Reston
Nov 26, 2024
Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team. Job Title: Clinical Appeals Specialist Location: Reston, VA (Remote) Summary: The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request. Essential functions: 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates. 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights. 25% Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accredidation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS. 5% Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications. Qualifications: Education Level: High School Diploma Education Details: Experience: 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting. Preferred Qualifications: 2 years experience in Medical Review, Utilization Management or Case Management at * Client Client, or similar Managed Care organization or hospital preferred. BSN/MSN Degree Knowledge, Skills and Abilities (KSAs): Knowledge and understanding of medical terminology., Advanced Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task , Proficient Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced Knowledge of Microsoft Office programs., Proficient Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions., Proficient Licenses/Certifications:** RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req CCM - Certified Case Manager Upon Hire Pref LNCC - Legal Nurse Consultant Certified Upon Hire Pref Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, age, protected veterans or individuals with disabilities.