Registered Nurse (RN) Provider Appeals Coordinator (Utilization Management) - Health Alliance Plan - Southfield

GENERAL SUMMARY:

• Investigate and prepare case summary for Provider Appeal and Code Review inquiries based on network, product, medical criteria, regulatory requirements and business rules. 
• Present case summary to Medical Directors and Committee members for review and decision.
• Review and make decisions for initial referral requests that include; elective admissions, elective procedures, DME, Home Care, Hospice and Home Infusion.
• Reviews referral request for appropriateness of setting, medical criteria, network and business rules, while adhering to all department and regulatory requirements.
• Presents case summary to Medical Director for decision according to departmental guidelines.    Under the Network Medical Director, coordinate and authorize services rendered out of network and with other contracted services as needed. 
• Consults with Medical Directors on referrals that are beyond the scope of coverage as outlined in the member contract, Benefit Administration Manual and for requests for services out-of-plan.
• Acts as liaison to all HAP Departments, such as Customer Service, Provider Development, Claims, Marketing and Quality Management.
• Participate in the development of alternative cost savings and quality management processes that include inpatient and outpatient utilization.
• Conduct pre-service and admission review for requests for outpatient service for HAP members.
• Review denied claims for medical necessity and will obtain additional documentation as required.
• Review medical records, appeals and claims for appropriateness of resolution.
• Assist Plan Medical Directors with review of cases and application of medical necessity criteria.
• Coordinates transition of care for new enrollees for medical care that cannot be interrupted.
• Establishes positive relationships with all clinical providers and insures appropriate communication occur.
• Reviews and makes decisions on requests for out-of-plan services for students away at school based on established criteria.
• Acts as a liaison between member, provider and HAP’s medical staff, to resolve conflict and promote positive outcomes.
• Identifies any real or perceived quality issues and reports to the Quality Management department.
• Identifies high risk or complex care cases and transitions those cases to the Care Management Team.
• Identifies potential stop-loss cases for AHL members and notifies responsible party.
• Understand and adhere to NCQA, CMS, DOL, ERISA and other mandatory regulatory requirements.
• Participate in planning and conducting utilization studies, including data collection, analysis and follow-up activities.
• Assist Medical Services department in the collection of medical information, such as HEDIS measures.
• Use established medical criteria to approve services based on information obtained from appealing, requesting providers, or member.
• Ensure full collection of clinical information prior to rendering a decision including contacting hospital or other providers for additional information as necessary.
• Manage workload needs on a concurrent basis, including provider appeals and medical components of member appeal cases, to concurrently prioritize self-assignment for greatest impact on department function.
• Create denial letters to members/providers as required and within established NCQA and CMS timeframes.
• If services are denied, accurately documents this process and provides timely facility and member notifications following specified timelines (CMS, DOL or NCQA) and department protocols.
• Identifies and determines medical necessity of out of network requests for services.
• Perform other related duties as assigned.