Description

UPMC Health Plan is hiring a full-time Lead, Clinical Appeals Coordinator to support the Provider Disputes team. The team is based out of downtown Pittsburgh's US Steel Tower, however, this role will work remotely (this is subject to change based on department needs). This role will predominantly work standard daylight hours Monday through Friday, however, occasional Saturday on-call availability may be required as needed. 

This position coordinates and reviews all types of clinical provider appeals, for all lines of business. The functions include reviewing cases for medical necessity and coordination with the Medical Directors. In addition, they will oversee the provider appeal clinical coordinator team on a day-to-day basis and provide guidance/assistance as necessary. The Clinical Appeals Coordinator Lead will be responsible for the distribution of work assignments for their team as well as workflow management within their team. They will also serve as a process subject matter expert and provide training and support to the clinical coordinator staff and others as needed. The incumbent must use their knowledge and expert understanding of clinical provider appeals and work with provider appeal team leadership to identify opportunities to improve clinical and appeal performance, including timeliness, accuracy and quality. Furthermore, the position requires the ability to articulate these opportunities, help implement the solutions, and track and monitor progress. These functions must be done while also weighing the practical considerations and potential barriers that need to be overcome to successfully implement new processes.

Responsibilities:

• Monitor day to day workload of clinical appeals staff. Assign clinical appeals. Manage workflow to maintain timely resolution of appeals. Serve as clinical and process expert and train staff as needed. Actively identifies and helps implement work process improvements to enhance team performance. Attends meetings on behalf of Management team. Assist with reporting, review of reports, and action planning. Assist with special projects and act as subject matter experts assigned. Review, investigate and complete complex, high-priority and executive appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes.
• Participate in a UPMC Health Plan clinical committee, such as Benefit and Reimbursement Committee( BRC), Ethics Committee, etc. Assist in the yearly review of the Provider Dispute P&PAct as resource and participate, as needed, in 2nd-level member hearings. Work closely with Special Investigations Unit (SIU), Network Development, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, Benefit Configuration, Compliance, Enrollment, Pharmacy Services, Reimbursement, Legal and Coding departments to ensure review processes are understood and meet Health Plan strategy for appropriateness of provider reimbursement as well as quality of care and services. Manage escalated provider issues as required. Review first and second-level appeals for medical necessity, completes comprehensive medical necessity packets summarizing clinical facts for the Medical Director review. Coordinates timely case review by a Health Plan Medical Director. Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc. )Review, investigate and decision audit appeals. This includes appeals that originated as audits from Special Investigations Unit (SIU) and Fraud, Waste, and Abuse (FWA). Interpret Medical Director notes and summarize into correspondence for providers. Track and trend appeals related to medical necessity, coding issues and other administrative reasons.Report trends to management and Network Development for improvement opportunities and provider education.
• Prepare an RN summary for the Medical Director. Respond to providers in writing with the results of appeal review in accordance with Provider Appeal Team/Claim Operations Department standards and all applicable regulatory requirements.Outreach to providers as appropriate to communicate decisions. Assist in the creation, enhancement and implementation of process workflows for the Provider Appeal Team/Claim Operations Department Assist with identifying continuing education needs and opportunities; maintain continuing education and appropriate CEUS required for RN licensure.

Qualifications

• Registered nurse with minimum of two years direct patient care experience required
• Minimum of 1 year experience working with complaints, grievances and appeals required.
• Four years of Health Insurance experience as a Registered Nurse in a Utilization Management/Medical Management role or related field strongly preferred.
• Prior supervisory or team lead experience preferred
• Experience with accountability for regulatory compliance for entities such as NCQA, CMS, Department of Public Welfare, Department of Health and Pennsylvania Insurance Department preferred.
• Excellent verbal and written communications skills required
• Working knowledge of insurance benefit packages preferred.
• Knowledge of relevant Federal and State regulations required.
• The ability to work in a fast-paced insurance environment and to handle multiple priorities/projects in a professional manner required.
• Working knowledge of ICD-9 and CPT classifications and coding of diagnoses and procedures required.
• Proficiency in computer skills required.
• Ability to collaborate effectively with physicians and other health care professionals.
• Strong organizational and problem-solving skills with ability to make decisions independently.

Licensure, Certifications, and Clearances:

• Registered Nurse (RN)
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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