Utilization Review Nurse-Medicare Appeals Reviewer (HealthSpring)
Location: Nashville, Tennessee
Description: Cigna is presently looking of Utilization Review Nurse-Medicare Appeals Reviewer (HealthSpring) right now, this occupation will be depute in Tennessee. Detailed specification about this occupation opportunity kindly see the descriptions.
CignaHealth Spring Medicare Appeals Reviewer:
We will depend on you to communicate some of our most critical information to the correct ind ividuals regarding Medicare appeals and related issues, implications and decisions. The Appeals Reviewer reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B and Part D drug. The Appeals Reviewer will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submissio n to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.
This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm - Monday through Friday. (weekend coverage with flexible week days off may be needed on occasion)
Qualifications
Job Requirements include, but not limited to:
- Must have experience in Medicare Appeals, Grievance, Utilization Case Management or Compliance in Medicare Part C
- Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.
- Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.
- Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied
- Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.
- Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director.
- Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response
- Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communicat ion process, etc.
- Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)
- Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance
- Adhere to department workflows, desktop procedures, and policies.
- Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.
- Read Medicare guidance documents report and summarize required changes to all levels department management and staff.
- Support the implementation of new process as needed.
- Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .
- Understand and investigate billing issues, claims and other plan benefit information. . < /li>
- Assist with monitoring, inquiries, and audit activities as needed.
- Additional duties as assigned.
Qualifications
- Education: Registered Nurse, Associate degree or higher.
- 3-5 years’ experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service
- Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10
- Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.
- Must have the ability to work objectively and provide fact based answers with clear and concise documentation.
Proficient in Microsoft Office products (Access, Excel, Power Point, Word). < li>Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases. - Ability to work independently and under pressure.
- Attention to detail and critical thinking skills.
Ability to multi-task and meet multiple competing deadlines.
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Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. Need an accommodation? Email: SeeYourself@cigna.com- .
If you were eligible to this occupation, please deliver us your resume, with salary requirements and a resume to Cigna.
Download resume objectives for high school graduates sample here.
Interested on this occupation, just click on the Apply button, you will be redirected to the official website
Apply Utilization Review Nurse-Medicare Appeals Reviewer (HealthSpring) Here
This occupation will be started on: Thu, 17 May 2018 23:44:34 GMT
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