Job Description
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first.We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Clinical Appeals Nurse is responsible for reviewing requests for appeals of both inpatient and outpatient services for all plan members. Position collaborates closely with providers, Regional and Senior Medical Directors and Utilization Management to ensure timely processing of appeals to provide the highest quality medical outcomes that are most cost efficient. General Duties and Responsibilities: Reviews and prepares appeal requests for medical necessity and refers to Medical Director any appeal that requires MD approval or denial Independently applies evidence-based clinical criteria (Milliman, InterQual, CMS NCD / LCD) to conduct objective medical necessity reviews and make appeal determination recommendations Maintain goals for established turn-around time (TAT) for appeal processing, in addition to managing expedited requests to ensure compliance with each appeal assigned Coordinate peer-to-peer conversations to maintain professional rapport with providers, physicians, support staff and additionally patients to efficiently process appeals Verify eligibility and / or benefit coverage for requested services when evaluating appeals Verify accuracy of ICD 10 and CPT coding in processing appeal requests Contact requesting provider and request medical records, orders, and / or necessary documentation to process an appeal when nec
