Clinical Appeals Specialist RN

4 days ago

Asheville, North Carolina, United States Vaya Health Full time
Job Title: Clinical Appeals Specialist RN

Vaya Health is seeking a highly skilled Clinical Appeals Specialist RN to join our team. As a key member of our Member Appeals Team, you will be responsible for the clinical review, consultation, and generation of Vaya Medicaid and State denial and appeals processes.

Key Responsibilities:

  • Prepare and generate nonclinical and clinical peer review referrals, acknowledgment letters, service authorization and appeal decision letters.
  • Consult with Vaya's Utilization Management Team, Medical Team, Pharmacy Team, and/or upon request by the Legal Team, the applicable delegated subcontractor in preparation for mediated settlement conferences.
  • Represent, or assist in the representation of, Vaya in mediated settlement conferences concerning medical and pharmaceutical services authorization decisions.
  • Maintain a professional and collaborative working relationship with other staff on the Member Appeals Team, the Utilization Management Team, the Legal Team, and other internal and external persons for a shared goal of advancing the mission, vision, and values of the organization.
  • Respond to requests from the Legal Team for documentation related to authorization or appeal decisions.
  • Assist members/ LRPs with filing oral and written appeal requests.
  • Upload appeals and related documentation in Vaya's administrative health record and other databases.
  • Provide support in conducting responsibilities in the appeals processes, including performing Personal Care Service appeal reviews, non-clinical appeals reviews, and administrative tasks (reviewing, auditing, logging, submitting, etc.) involved in the denial and appeal processes.
  • Support the work of the Appeals Specialists in generating such correspondence and the accompanying administrative tasks.
  • Support the work of the Appeals Team in maintaining appropriate electronic denials and appeals files.
  • Follow and track cases through all levels of the appeals processes, including at the plan-level, State Fair Hearing level, judicial review, and appellate level.
  • Maintain accuracy and maintenance of the Peer Review and the Denial and Appeal Logs.
  • Regularly communicates with the Utilization Management Team and delegated subcontractors on a daily basis concerning denial and appeal letter requests.
  • Assist Member and Recipient Appeals Manager in monitoring and auditing Appeals Team files.
  • Assist in implementing any corrective action plans as needed to improve denial and appeal processes.
  • Support the Member and Recipient Appeals Manager and Appeals Team in ensuring timely and accurate collection and reporting of data regarding denial and appeal process. This includes generation of notices in a timely manner, appeal rates, appeal outcomes, etc.
  • Assist with analysis of data, reporting of anomalies and generation of report outs.

Requirements:

  • Bachelor's degree in Nursing (Physical Health) with licensure as an RN.
  • Two years of post-degree professional experience.
  • Active RN Licensure in the State of North Carolina.

Preferred Qualifications:

  • Knowledge and experience with Integrated Health and Managed Care preferred.

Physical Requirements:

  • Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
  • Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
  • Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
  • Mental concentration is required in all aspects of work.

Residency Requirement:

This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

Salary:

Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

Deadline for Application:

Open Until Filled

Apply:

Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.

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