Murtech

Role Description This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members. Responsibilities - Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. - Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. - Compose clear and concise rationales for members and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). - Ensure that all aspects of the medical management process are consistent with community standards of care. - Participate as a member of the CMDM multidisciplinary team. - Attend huddles and grand rounds. - Advise multidisciplinary team on cases that require physician expertise. - Participate in protocol and guidelines development to ensure consistency in the review process. - Actively manage projects and/or participate on project teams that require a physician subject matter expert. Qualifications - Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) - 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) - Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards - Active medical state licensure required for PA, NY, or WV. - Critical Thinking - Case Management - Customer Service - Oral & Written Communication Skills - Collaboration - Listening - Telephone Skills - General Computer Skills - Clinical Software - Managed Care Preferred Qualifications - Master's Degree in Business Administration/Management or Public Health - 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Appeal & Grievance Coordinator will receive, investigate, and triage expedited appeal requests from members and provider representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure that appeal rights are processed in accordance with regulatory standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). - Claims research and processing (more focused on understanding why claims were denied) - Authorization lookup/building authorizations and updating them - Researching outside vendor sites for authorizations and reviewing notes - Reviewing appeal letters to determine the basis of the provider's appeal - Starting the appeal process and conducting research on the appeal - Sending out appeal determination letters and completing the appeal - Extensive training on internal and external systems and the internal appeal process Qualifications - At least 1 year of experience in health insurance claims and appeals is strongly preferred - At least a high school degree; a college degree and/or extensive experience would be considered - Outbound call experience (though not a large part of this job) is a plus - A customer service background and experience, not necessarily in the healthcare field, is a nice to have - Medicaid experience desired and will make the candidate stand out