Utilization Review Nurse - Appeals

Cigna Medicare Part C Appeals Reviewer: Appeals Processing Analyst

We will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions. The Case Management Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs. The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.

This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm CST - Monday through Friday with occasional weekend and holiday coverage.

Job Requirements include, but not limited to:

Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C

Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.

Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.

Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied

Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.

Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director.

Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response

Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.

Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc. )

Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance

Adhere to department workflows, desktop procedures, and policies.

Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.

Read Medicare guidance documents report and summarize required changes to all levels department management and staff.

Support the implementation of new process as needed.

Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers.

Understand and investigate billing issues, claims and other plan benefit information.

Assist with monitoring, inquiries, and audit activities as needed.

Additional duties as assigned.

Qualifications

Education: Licensed Practical Nurse (LPN) or Registered Nurse (RN)

3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service

Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10

Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.

Must have the ability to work objectively and provide fact based answers with clear and concise documentation.

Proficient in Microsoft Office products (Access, Excel, Power Point, Word).

Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.

Ability to multi-task and meet multiple competing deadlines.

Ability to work independently and under pressure.

Attention to detail and critical thinking skills.

Learning and Applying Quickly

A relentless and versatile learner

Open to change

Analyzes both successes and failures for clues to improvement

Experiments and will try anything to find solutions

Enjoys the challenge of unfamiliar tasks

Quickly grasps the essence and the underlying structure of anything

Written Communications

Is able to write clearly and succinctly in a variety of communication settings and styles

Can get messages across that have the desired effect

Functional/Technical Skills

Clinical and Non Clinical functional or technical proficiency

Appropriate judgment and decision making because

Knowledge of applicable policy and business requirements

Computer skills and ability to work in various system applications.

Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishment

Time Management

Spends his/her time on what's important

Quickly zeros in on the critical few and puts the trivial many aside

Can quickly sense what will help or hinder accomplishing a goal

Eliminates roadblocks

Uses his/her time effectively and efficiently

Concentrates his/her efforts on the more important priorities

Gets more done in less time than others

Can attend to a broader range of activities

Problem Solving

Uses rigorous logic and methods to solve difficult problems with effective solutions

Probes all fruitful sources for answers

Can see hidden problems

Looks beyond the obvious and doesn't stop at the first answers

Is excellent at honest analysis

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 19 - 29 USD / hourly, depending on relevant factors, including experience and geograp.