Clinical Appeals Manager

Found in: Talent US C2 - 2 weeks ago

Westfield, United States Bierman ABA Full time
Job Type Full-time Description

The Clinical Appeals Manager will oversee the clinical appeals process, ensuring timely and accurate handling of cases in alignment with state and federal regulations. The role includes conducting medical necessity reviews, advocating for clients' access to essential treatments, and acting as a liaison between clients and insurance providers. The Clinical Appeals Manager will ensure compliance with healthcare laws and policies, perform treatment plan integrity checks, and drive quality improvement initiatives to enhance client care outcomes. This crucial position requires strong analytical, communication, and advocacy skills to effectively navigate the complexities of healthcare appeals and insurance processes.

Why You’ll Love Bierman:

Competitive Compensation and Comprehensive Benefits : Enjoy a competitive salary and comprehensive benefits package, including Paid Time Off, 401k, health, dental, and vision insurance, and the option of Short and Long-Term disability insurance. Engaging and Supportive Culture : Embrace our entrepreneurial and open culture that values teamwork, collaboration, and continuous improvement. Experience a work environment that celebrates purpose-driven initiatives and collective achievements. Flexibility and Remote Work : Work remotely or from our Indianapolis office, depending on your location. Enjoy the convenience and autonomy of remote work while making a meaningful impact. Professional Growth Opportunities : Benefit from training, mentorship, and opportunities to expand your skills and knowledge within the behavioral healthcare industry. We are committed to your professional development.

Key Responsibilities:

Appeals Management and Coordination: 

Prepare clinical appeals, Determine the most suitable responses, advocating for the client's access to medically necessary treatments in compliance with generally accepted standards of care. Facilitate external review ensuring timely completion of cases.  Manage denials, requests for appeal, and preparing documentation for review, in accordance with state and federal laws Conduct comprehensive reviews for medical necessity and appropriate levels of care, formulating conclusions promptly. 

Client Support: 

Act as a liaison between Bierman clients and insurance companies.  Provide detailed explanations regarding the appeal process, including the status of appeals, ensuring timely communication.  Assist families in understanding plan benefits, exclusions, and the importance of adherence to appeal timelines and procedures as stipulated by insurers and regulatory bodies.

Policy and Procedure Compliance: 

Ensure adherence to internal and external policies and guidelines related to clinical appeals, including understanding and applying state-specific regulations.

Documentation and Record-Keeping: 

Request, obtain, and review medical records and other pertinent documents to support appeal cases.  Ensure all appeals documentation is accurately recorded in the electronic system in real time, following strict guidelines for privacy and confidentiality.

Quality Assurance and Improvement:

Regularly review and analyze appeal processes and outcomes to identify trends, inefficiencies, and areas for improvement.  Implement strategies to enhance the success rate of appeals, reduce denials, and improve patient access to necessary care.

Treatment Plan Integrity Checks: 

Conduct thorough integrity checks of treatment plans to ensure they align with evidence-based practices, client-specific needs, and medical necessity criteria. 

Maintain a client caseload as needed

Perform other duties as assigned

Requirements Must be a Board Certified Behavior Analyst (BCBA) or BCBA-D. Experience at an insurance company or in a similar role is highly preferred. Strong understanding of ABA therapy and its application in clinical settings. Excellent communication and interpersonal skills, with the ability to work collaboratively with a diverse team. Proficient in data entry and the use of electronic health record systems. Ability to manage multiple tasks simultaneously and meet deadlines. Commitment to maintaining the highest level of confidentiality and professionalism.

Basic & Physical Requirements

Must have manual dexterity to perform specific computer and electronic device functions  Must have visual acuity to read and comprehend written communication though computer, electronic devices, and paper means. Must be able to maintain prolonged periods of working on a computer while sitting at a desk and attending virtual meetings

About Bierman Autism Centers:

Our goal is to fuse science and learning to accelerate progress and transform lives. We were established in 2006 with a simple focus on providing excellent therapy for children with autism and building a unique and fun environment for team members and children to thrive. We live by the culture we’ve created and our core values: to create a fun and stimulating learning environment, empower individuals and treat them with kindness, integrity, and respect, never sit still, achieve, and continuously raise the bar, team above the individual, build a sustainable organization that leaves a meaningful impact on lives, and adhere to our core principles without compromise. Together, we change lives

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