The incumbent monitors and reports on all mediation and appeal requested by applicants and beneficiaries whose clinical assessment results in a denial or reduction in health care services.
1. Processes correspondence, appeals, program reviews, reports and other requests.
2. Serves as a content knowledge expert regarding business rules of the project; review/research mediation and appeals cases.
3. Works closely with the Clinical Director and Program Managers in assisting with resolving difficult and complex cases.
4. Works closely with the Clinical Director and Program Managers to investigate issues raised by clients in their correspondence, appeals and requests.
5. Creates letter requests in response to applicant inquiries regarding case status, appeals, and other written requests.
6. Works closely with team to accurately adjudicate appeals and determine the outcome of the case.
7. Participate in mediation and appeals hearings as requested by
8. Provides the Clinical Director and Program Managers with updates on all issues regarding quality, training, policy & procedures.
9. Meets all standards established for this position as outlined in the attached performance criteria.
10. Performs other duties, as necessary or assigned by the manager.
Knowledge, Skills & Abilities
• Experience handling inquires, complaints and appeals
• Experience in level of care/service eligibility determinations in health, human services or a related field
• Excellent organizational, interpersonal, written, and verbal communication skills
• Excellent analytical and complex reasoning skills
• Ability to perform all job duties in compliance with Person First standards, HIPAA guidelines, and company confidentiality policies
• Ability to multitask effectively while performing job duties, including ability to prioritize tasks and ensuring all voice mail and email messages are returned within six business hours of receipt
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Ability to successfully execute many complex tasks simultaneously
• Ability to work as a team member, as well as independently
• Intermediate skill with word processing, spreadsheet, presentation, and publishing software (Microsoft Word, Excel, PowerPoint, Publisher, and Visio strongly preferred)
The job requires a Registered Nurse licensed in North Carolina. Experience working with individuals with chronic medical conditions and/or cognitive impairment preferred. Experience making level of care determinations also preferred.
The job requires at least three (3) years of experience within a healthcare, mental health, or long-term care setting.