Vacancy expired!
Behavioral Health Appeals Coordinator Sr. PS26137Location: United StatesNewRequisition #: PS26137Responsible for investigating and processing the most complex grievances and appeals requests from members and providers related to behavioral health services. Serves as a technical resource to team and may be assigned to work on projects in support of medical policy and/or managed care initiatives. Primary duties may include, but are not limited to: Investigates and reviews member and provider grievances and appeals. Generally works on issues that are of a complex nature. Serves as an internal resource for lower level behavioral health appeal coordinators and staff. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to medical director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs information on tracking systems and mainframe systems. Generates appropriate written correspondence to providers, members, and regulatory entities. Participates in projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives. Requires an MS in social work, RN or degree in a related behavioral health field; 4 years of experience in a managed care/healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor or RN license to practice as a health care professional within scope of licensure in applicable state(s) or territory of the United States required.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.AnEqualOpportunityEmployer/Disability/Veteran
