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The Special Initiative Coordinator will be responsible for medical necessity reviews specific to Inpatient Sepsis, Emergency Room claims, and other initiatives created requiring chart reviews for proper leveling for claims payment. Process provider appeals based on the request from the provider as indicated on the Clinical Appeals Form. Work collaboratively with Claims, Provider Relations, or other departments to ensure appeal processed timely and in accordance with regulatory requirements.ACCOUNTABILITIES
Complete medical necessity review as indicated and process provider appeals based on the request from the provider in cover letter or completed form for final resolution. Work collaboratively with Claims, Provider Relations, or other departments to ensure appeal processed timely and in accord with regulatory requirements / Adjust claims if necessary
Process provider appeals based on appeal type, appeal category, and member implications
Facilitate Medical Director review/appeal determination as necessary / communicate in writing and in accordance with regulatory guidance the appeal outcome
Prepare monthly report(s) for Director / Manager, Utilization Management outlining appeals statistics, as well as analyze for trends and opportunities for UM cost savings and/or provider/staff education. Assure accurate, timely, and appropriate UM appeals reporting
Monitor appeals related to ODM, CMS, ODI, NCQA compliance indicators, and facilitate team processes for compliance of same
Collaborate with the Utilization Management Compliance Coordinator to assure compliance for provider appeals processing and monitoring
Draft and maintain up-to-date departmental appeals procedures
Perform other duties as directed
Job Requirements:Education: Associates Degree in Nursing: Bachelor's degree preferred.Skills:
Experience in a provider setting with demonstrated problem-solving and organizational skills, excellent oral and written communication skills and effective interpersonal skills strongly preferred
Recent experience in public health, managed care, or quality improvement environment required
Ability to develop and present data in meaningful ways to clinical and financial staff
Strong knowledge of governmental regulations related to member/provider appeals and grievances.
Demonstrated ability to handle confidential information in a professional and appropriate manner required.
Demonstrated working knowledge in Word, Excel, Outlook, and internet preferred.
Demonstrated organizational and time management skills.
Must possess the ability to work independently and within a team
Excellent oral and written communication and organizational skills
Ability to plan, coordinate, and organize multiple priorities & exercise independent judgement
Ability to move between company workstations and departments
Ability to communicate on telephones and operate general office equipment, including computers
Years of Experience: Minimum 3 years of relevant RN experience, 5+ years preferred.License: Current Ohio and Michigan nursing license (Michigan registered nurse’s license must be obtained within three months of employment)ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. It serves communities in 28 states. The organization offers acute and ambulatory care, an insurance company with a dental plan, and post-acute and academic business lines. The organization has more than 56,000 employees, 13 hospitals, 2,100+ physicians and advanced practice providers with privileges, 900+ healthcare providers employed by ProMedica Physicians, a health plan, and nearly 400 assisted living facilities, skilled nursing and rehabilitation centers, memory care communities, outpatient rehabilitation clinics, and hospice and home health care agencies. Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. For more information about ProMedica, please visit www.promedica.org/aboutus.Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity or gender expression, age, disability, military or veteran status, height, weight, familial or marital status, or genetics.Equal Opportunity Employer/Drug-Free WorkplaceRequisition ID: 51080
