Ultimate Staffing is seeking individuals with experience handling case management in response to risk and processing appeals requests for a large Behavioral Health Company in Maryland Heights, MO.
Maintains a caseload and monitors day to day compliance of appeal decision time frames.
Reviews clinical and medical records for completeness and determines administrative or clinical appeal.
Assigns reviews to physician advisers and medical directors for those requiring medical necessity reviews.
Enters all data related to appeals and case reviews into a database.
Prepares and presents information on appeals to panels second-level multi-disciplinary committee.
Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors Quality Improvement activities of appeals department, and assists in the development of depart flows and implementations.
Coordinates and distributes first, second and third level appeal request assignments.
Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
Organizes volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed.
We are an equal opportunity employer and make hiring decisions based on merit. Recruitment, hiring, training, and job assignments are made without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, or any other protected classification. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.