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Clinical Appeals Advisor

Company: InnovAge
Location: Denver
Posted on: July 1, 2020

Job Description:

Job Summary The Clinical Appeals Specialist is responsible for coordinating appeals from receipt to resolution; investigates participant appeals in accordance with PACE regulations, federal and state laws; and adheres to department policies regarding quality and timeliness, and by maintaining accurate and tracking and reporting of all appeals to regulatory agencies. Under the supervision of the Chief Compliance Officer the Clinical Appeals Specialist process appeals, analyze, research, and provide comprehensive responses in accordance with established regulatory guidelines. Collaborate with InnovAge staff, participants and/or designee to gather information and communicate disposition of case. Conduct pertinent research in order to evaluate, respond to, and finalize appeal. Familiar with standard concepts, practices, and procedures for analyzing, interpreting data and applying PACE benefit and regulatory provisions. Essential Functions and Work Responsibilities Functional Category: Managing Participant Appeals Process-100% Provide written acknowledgment of appeal and other participant correspondenceEnsures thorough, accurate, timely processing of participant appeals using the internal appeals process.Ensures thorough, accurate, timely processing of participant appeals using the Medicaid and/or Medicare appeals process.Gather all documentation to support position of interdisciplinary teamPrepares comprehensive position statement for Medicare and state Medicaid appeals hearingsServes as a liaison in corresponding and communicating with providers, interdisciplinary staff teams, participants, and/or participant's authorized representativeMaintain thorough knowledge of internal policies, procedures, regulations, for accurate resolution of appeals, including new and existing laws and regulations. Develop/prepare reports regarding the types/volumes/causes of inquiries received.Correspond with external appeals reviewer. Review and process all correspondence including approvals and denials/adjustments, and results from various levels of appeals. Communicate appeals decision to the participant within regulatory guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws. Review, prepare, and summarize cases for CMS and/or state Medicaid audits.Work collaboratively in an objective, diplomatic and professional manner with all parties involved in an appeal.Assist in racking appeals and departmental reporting.Perform other duties as assigned. Travel Requirements Travel Travel between local InnovAge CentersOccasional travel to Participants place of residence such as Assisted Living Facilities, private homes etc. and/or other off site locationsOccasional overnight travel out of state Job Qualifications Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions REQUIRED Education Bachelors of Science degree in Nursing Licensure, Certification, Registration or Designation Current RN license
Must have a state issued driver's license, personal transportation, good driving record and auto insurance as required by law Work Experience and Qualifications Must have a minimum of five (5) years' experience of applied clinical experience as an RN in a health care provider related field.
Must have a minimum of three (3) years' experience working with grievances and appeals, case management, utilization management for a health plan or medical group.
Past experience in healthcare industry. PREFERRED Education
Masters of Science in Nursing
Paralegal certification Work Experience and Qualifications Past experience in Grievance and Appeals Unit or Department for a health plan or medical group
Strong knowledge of health care, long term care, and homecare experience, preferred.

Keywords: InnovAge, Denver , Clinical Appeals Advisor, Healthcare , Denver, Colorado

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