RN Appeals Coordinator

Job Summary The Appeals Coordinator is accountable for reviewing appeals pursuant to an adverse benefit determination within the time frames set forth in both federal and state law by applying corporate and medical guidelines and policies. This position requires extensive knowledge of Federal, State, payer regulations, and reimbursement methodologies to facilitate timely and accurate reimbursement. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether or not an adverse benefit determination was legal, appropriate, impartial and fair.

This position reports to Senior Counsel.

RequirementsEDUCATIONBachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.

EXPERIENCE Minimum five (5) years' clinical nursing experience, to include a broad background in various facets of nursing.

Knowledge of HCPCS/CPT/Revenue codes and general coding principles.

Knowledge of claims processing rules/logic.

Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.

Minimum two (2) years' in utilization review, medical policy, and/or case management experience required. Previous experience in appeals and/or grievances process preferred.

ESSENTIAL SKILLS & ABILITIES Excellent oral & written communication skills

Detail-Oriented Strong analytical, critical thinking, organizational and time management skills

Proficiency using basic computer skills in Microsoft Office such as Word, Excel, Outlook, and PowerPoint, including the ability to navigate multiple systems and keyboarding.

Ability to make sound judgments and decisions based on facts and guidelines.

Ability to build collaborative relationships.

Ability to work independently with little supervision.

Ability to interpret complex documentation.

Skills
• Analytical Decision Making
• Business Compliance
• Collaborative Communications
• Critical Thinking
• Cross-Functional Communications
• Data Analysis
• Document Recording
• Information Interpretation
• Interpersonal Relationship Management
• Law• Microsoft Excel
• Microsoft Office
• Needs Assessment
• Researching• Sound Judgment
• Time Management Responsibilities
• Appeals:
Researches appeal cases for diagnosis codes and medical necessity; provides comprehensive responses, according to accepted standards of medical practice and corporate medical policy, code review logic, contractual guidelines and regulatory requirements.
• Communication:
Collaborates with various medical divisions concerning legal issues related to benefits and must be able to understand and explain medical coverage policy application. Respond to the Arkansas Insurance Department and any other state insurance department who has received a complaint and to any appeal of an adverse benefit determination made by a member, provider, attorney or personal representative of a member of Arkansas Blue Cross within the timeframe allowed by state and federal law.
• Compliance:
Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Knowledge:
Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
• Other duties as assigned.

Certifications Registered Nurse (RN) - Arkansas State Board of Nursing Security Requirements This position is identified as level three (3). This position must ensure the…