The Appeals & Denials Team Lead is responsible for management of the Pre-Service Denial and Appeal division of the health plan. Successfully maintains National Committee for Quality Assurance (NCQA), URAC or general accreditation status with regard to denial letters. Responsible for the writing and final editing of all letters sent out for denials and appeals. Ensures that each employee that is part of the denial process is meets their timeline with a 100% accuracy rate.
Current licensure to practice as a Registered Nurse or a Licensed Practical Nurse in the designated State, without restriction. Three to five years of experience, education and/or certifications in utilization management, case management or other appropriate health care specialty. Knowledge of MHP’s mission and operational structure. Knowledge of managed care, particularly utilization management processes. Knowledge of Medicaid guidelines, medical necessity and benefit structure. Knowledge of NCQA, URAC or general accreditation requirements and guidelines for utilization management, denials and appeals.
- Responsible for managing all aspects of the denial and appeal processes within the department to promote consistency and accuracy within the processes and compliance with NCQA, URAC or general accreditation, MDCH and HIPAA guidelines
- Daily prioritization of staffing assignments for optimizing impact on department production
- Responsible for each IRO supporting the health plan’s decisions and ensures that they meet the critical time lines
- Attends weekly post service appeals committee; understands each case and is prepared with review for each case
- Works with the Fraud, Waste and Abuse unit verifying claims issues on take backs
- Works with the IS department on MCS development issues as it pertains to appeals and denials
- Prepares, with the department assistant, each second level Pre-Service appeal for review by the appeals committee. Materials are prepared when the call to the member is placed.
- Educates the department assistant on all phone calls between the health plan and members.
- Reviews and participates in all appeals that go to the tribunal hearings. Assists with the preparation and ground work for each hearing maintaining a better than 99% reached verdict in favor of the health plan
- Assists the Member Service department with the member complaints
- Assists the Pharmacy department in their denial process
- Responsible for clinical coordination and presentation of information for administrative hearings and OFIR reviews
- Oversees the OFIR complaints; researches and writes the letters to support the health plans decisions
- Provide ongoing training and education to the staff through one-on-one and classroom settings regarding InterQual, NCQA, URAC or general accreditation, MDCH and other necessary job-related skills.
- Utilize professional knowledge, MHP knowledge and pertinent resources or use the appropriate reporting structure to solve problems and issues as identified
- Maintain strict confidentiality of employee and organizational information in accordance with MHP, HIPAA and State privacy regulations
- Perform other duties as assigned
Meridian Health Plan - 7 months ago
OmniCare Health Plan strives to care for everyone, or at least everyone in the southeast Michigan area. The company provides health...