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Appeals Clinical Reviewer

Job Description

ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare’s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.

We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.


Purpose:  To facilitate the accurate administration of benefits, maximize optimal appropriate utilization related to medical necessity, and place of service to foster high quality care in a cost effective environment.


Key Accountabilities:

  1. Reviews clinical cases, utilizing the appropriate clinical criteria, CMS guidelines, and medical and administrative policies to evaluate medical necessity.
  2. Utilizes the member’s contract to determine eligibility.
  3. Reviews appeal files for completeness and accuracy, and investigates deficiencies.
  4. Prepares and presents clinical detail, including the necessary medical necessity criteria and forming the issues to be addressed, to ConnectiCare’s (“CCI”) Medical Director or Pharmacist, or Independent Review Organization in accordance with state and federal regulations, NCQA requirements, and internal policy.
  5. Effectively communicates decisions to practitioners, providers, and members verbally and/or in writing in an accurate, timely, and professional manner.
  6. Ensures regulatory and internal time frames are met.
  7. Consults with internal areas as required (e.g., the Legal Department) to clarify ramifications around complex appeals.
  8. Reports any quality of care or service issues or serious adverse events identified through the appeals process to the appropriate staff for investigation and processing.
  9. Assists with processing Department of Insurance Complaints related to medical necessity determinations. After complete review, makes a sound decision as to whether or not a denied service or claim should be reversed or consult with the Medical Director in the decision-making process.
  10. Enters and maintains documentation of critical data and records in compliance with regulatory requirements and NCQA standards and in support of CCI’s business requirements.
  11. Tracks and trends outcomes, analyzes data, and reports on these to the Director as required.
  12. Identify areas for quality improvement and makes recommendations for the revision of policy and procedure(s) as necessary.
  13. Acts as a clinical resource to the non-clinical Appeals staff.
  14. Actively participates in assigned committees.
  15. Performs other duties as assigned.


Technical Knowledge, Experience, Skill Requirements

  1. RN license in CT. A Bachelor’s Degree in nursing required or an equivalent combination of education and experience.
  2. At least 5 years of clinical experience required.
  3. At least 3 years of experience in managed care setting preferred.
  4. Strong oral and written communication skills.
  5. Excellent analytic and presentation skills required.
  6. Excellent organizational and negotiation skills required.

ConnectiCare is an equal opportunity employer. M/F/D/V

ConnectiCare is a drug-free workplace.  Candidates are required to pass a drug test before beginning employment.

Job Requirements

 

Job Snapshot

Location US-CT-Farmington
Employment Type Full-Time
Pay Type Year
Pay Rate N/A
Store Type Health Care
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Company Overview

ConnectiCare

We’ve been helping make Connecticut healthier since we were founded in 1981 by a group of doctors. We live and work in the same communities as our members, so we’re able to do more for you. Whether it’s helping find a doctor or providing new, easier ways to get care and service, you can count on ConnectiCare, because caring goes with the territory. Learn More

Contact Information

US-CT-Farmington
Snapshot
ConnectiCare
Company:
US-CT-Farmington
Location:
Full-Time
Employment Type:
Year
Pay Type:
N/A
Pay Rate:
Health Care
Store Type:

Job Description

ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare’s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.

We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.


Purpose:  To facilitate the accurate administration of benefits, maximize optimal appropriate utilization related to medical necessity, and place of service to foster high quality care in a cost effective environment.


Key Accountabilities:

  1. Reviews clinical cases, utilizing the appropriate clinical criteria, CMS guidelines, and medical and administrative policies to evaluate medical necessity.
  2. Utilizes the member’s contract to determine eligibility.
  3. Reviews appeal files for completeness and accuracy, and investigates deficiencies.
  4. Prepares and presents clinical detail, including the necessary medical necessity criteria and forming the issues to be addressed, to ConnectiCare’s (“CCI”) Medical Director or Pharmacist, or Independent Review Organization in accordance with state and federal regulations, NCQA requirements, and internal policy.
  5. Effectively communicates decisions to practitioners, providers, and members verbally and/or in writing in an accurate, timely, and professional manner.
  6. Ensures regulatory and internal time frames are met.
  7. Consults with internal areas as required (e.g., the Legal Department) to clarify ramifications around complex appeals.
  8. Reports any quality of care or service issues or serious adverse events identified through the appeals process to the appropriate staff for investigation and processing.
  9. Assists with processing Department of Insurance Complaints related to medical necessity determinations. After complete review, makes a sound decision as to whether or not a denied service or claim should be reversed or consult with the Medical Director in the decision-making process.
  10. Enters and maintains documentation of critical data and records in compliance with regulatory requirements and NCQA standards and in support of CCI’s business requirements.
  11. Tracks and trends outcomes, analyzes data, and reports on these to the Director as required.
  12. Identify areas for quality improvement and makes recommendations for the revision of policy and procedure(s) as necessary.
  13. Acts as a clinical resource to the non-clinical Appeals staff.
  14. Actively participates in assigned committees.
  15. Performs other duties as assigned.


Technical Knowledge, Experience, Skill Requirements

  1. RN license in CT. A Bachelor’s Degree in nursing required or an equivalent combination of education and experience.
  2. At least 5 years of clinical experience required.
  3. At least 3 years of experience in managed care setting preferred.
  4. Strong oral and written communication skills.
  5. Excellent analytic and presentation skills required.
  6. Excellent organizational and negotiation skills required.

ConnectiCare is an equal opportunity employer. M/F/D/V

ConnectiCare is a drug-free workplace.  Candidates are required to pass a drug test before beginning employment.

Job Requirements

 
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