Clinical Appeals-RN

Universal American is a Fortune 500 company with offices throughout the United States. The company offers health insurance, and also deals in Medicare managed care plans, and Medicare prescription drug benefits.

Universal American has been on the cutting edge of healthcare for over 2 decades, pioneering innovative collaborations between patients/doctors to produce healthy outcomes. Universal built their business model around the concept that PCPs are in the best position to drive significant improvements in cost and quality of healthcare. As a company, Universal enables them by providing a structure that offers appropriate incentives for such improvements and actionable information that helps them achieve goals.

This concept underlies their long term success in serving the needs of people with Medicare and/or Medicaid.

Day to Day Responsibilities:

The Clinical Appeals RN performs the clinical appeals in accordance with internal policy and procedures, as well as regulations and time frames set forth by the New York State Medicaid Contract. The Clinical Appeals RN is responsible for timely assembly of the materials used for decision making from the Plan’s prior payment or service denial, and the thorough evaluation of those records and any new appeal information or documentation that was submitted with the appeal according to Medicaid coverage guidelines and other acceptable medical criterion.

Additionally, the Clinical Appeals RN is responsible for preparing clinical information and other supportive coverage guidelines to present to the Medical Director or external Physician Reviewer for their reconsideration (appeal) determination.

• Exhibits a thorough understanding of Medicaid Contract and Managed Care Legislation in regard to appeals processing guidelines.
• Thoroughly reviews all supporting information and requests additional information and/or medical records as required.
• Applies contract language, benefits and covered services in researching and deciding the outcome of appeals.
• Analyzes cases and identifies those which require escalating or expedited review, and adheres to associated time frames for timely completion of the appeal review process.
• Evaluates the necessity, appropriateness of medical services and procedures requested; then forwards all appeal cases with supportive criteria, guidelines, and protocols to an internal or external Physician Reviewer in the appropriate specialty for final determination.

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• Familiar with Medicaid contract and Managed Care Legislation in regard to appeals processing guidelines