This is a fully remote position, open to applicants in Alabama, +35 more states.

📋 Description

• Develop and address clinical cases related to pre-existing conditions, prior approvals, medical necessity, pre-certification, continued stay, reductions, terminations, and suspensions of services.

• Investigate issues and consult internal health plan policies and procedures.

• Analyze regulations and make essential decisions regarding case resolution.

• Maintain updated file notes and case summaries.

• Handle responsibilities within regulatory timeframes.

• Communicate efficiently to transfer and receive work from colleagues.

• Achieve productivity and quality benchmarks.

• Prepare cases for Medical Director Review, including comprehensive case summaries, contract details, responses, diagnoses, and CPT codes with descriptions.

• Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal across all levels of appeal.

• Oversee an individual caseload.

• Address Department of Health and executive complaints as necessary.

• Manage clinical claim appeals from both participating and non-participating providers as required.

• Participate in A&G/Operations divisional meetings and Town Halls, with occasional travel to specified locations.

⛳️ Requirements

• RN, LPN, or Dental Hygienist license.

• Bachelor’s degree is preferred.

• Experience in clinical practice, particularly in appeals & grievances, claims processing, utilization review, or utilization management/case management.

• Proven understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare local coverage guidelines.

• Proficiency in working independently with Microsoft Word and Excel, corporate email, and virtual filing systems such as Macess.

• Familiarity with care management systems such as CCMS, TruCare, and Hyland.

• Ability to handle large caseloads and perform effectively in a fast-paced environment.