Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country. We employ and provide care to people from all walks of life. We are committed to promoting healing, providing hope, preserving dignity and producing value with an inclusive workforce in which diversity is leveraged, respected, and reflective of the patients, family members, customers and team members we serve.
Appeals Coordinator
Location
United States
Posted
8 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Appeals Coordinator
Lifepoint Health
Role Description The Appeals Coordinator gathers all information required for an appeal, writes, and submits the appeal to the insurance company, makes follow-up phone calls, and maintains documentation of all steps taken. The Appeals Coordinator uses clinical criteria guidelines and clinical documentation to develop sound and well-supported appeal arguments to support medical necessity. The Appeals Coordinator works independently and collaboratively with other departments to positively affect clinical and financial outcomes. - Display knowledge of clinical pertinence and managed care requirements to support medical necessity criteria for inpatient and outpatient levels of care. - Verify the information needed by the insurance plan for an appeal, where to submit the appeal, and method of submitting appeal. - Manage large volumes of documents including copying, faxing and scanning incoming mail. - Document and log information on tracking systems and mainframe systems. - Ensure appeals are completed thoroughly and on a timely basis. - Interface with managed care organizations, external reviews, and other payers. - Obtain access to various provider portals and utilize portals for submitting appeals and following up on status of appeals when applicable. - Communicate with facility UR staff when needed to efficiently complete the appeal process. Qualifications - Bachelor’s Degree in social work, RN or degree in a related behavioral health field. - Minimum of 2 years of experience in a managed care/healthcare setting. Requirements - Previous utilization review experience in a psychiatric healthcare facility preferred. - Computer proficiency in Microsoft Office applications and other software programs essential to perform job functions. - May be required to work flexible hours and overtime. Benefits - Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees. - Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off. - Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match. - Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs). - Professional Development: Ongoing learning and career advancement opportunities.
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• Investigate and process medical necessity requests from both members and providers • Conduct and lead investigations and reviews for member and provider medical necessity appeals • Review the medical record of denied services for medical necessity • Provide a summary of case for the medical director, and other partners in the health plan care team • Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements • Document and log case information for the appeal • Generate the written response to the member or provider • Serve as a subject matter expert for appeals and grievances
• Investigate and process medical necessity requests from both members and providers • Conduct and lead investigations and reviews for member and provider medical necessity appeals • Review the medical record of denied services for medical necessity • Provide a summary of case for the medical director and other partners in the health plan care team • Ensure that appeal timeframes are met and meet the standards of enterprise, state, and federal standards and requirements • Document and log case information for the appeal • Generate the written response to the member or provider • Serve as a subject matter expert for appeals and grievances • Commit to a career of life-long learning and continuous improvement of processes related to Utilization Review
Clinical Coordinator
Rasmussen UniversityA university accredited by the HLC dedicated to changing the lives and communities we serve through education.
• Ensure Clinical Experiences Support Curriculum Delivery (50% or more) • Build relationships with health care facilities and potential adjunct faculty. • Collaborate with Dean of Nursing, Area Dean of Nursing, or Regional Dean of Nursing to identify clinical experiences that are evidence-based; reflect contemporary practices and nationally established patient health and safety goals; and support the achievement of the end-of-program student learning outcomes. • Review written agreements for clinical practice agencies to ensure they are current, specify expectations for all parties, and ensure the protection of students. • Review evaluation findings related to clinical experiences and report them to the Dean of Nursing, Area Dean of Nursing, or Regional Dean of Nursing. • Collect, document and store all required student programmatic paperwork according to University and programmatic policies. • Assist with the clinical course scheduling as directed by Nursing Deans. • Collaborate with the campus staff to assign student clinical placement and collect required documentation. • Track and maintain all community-based activities in Sales Force as appropriate, utilizing the Clinical Tracking Tool as the primary database for clinical activities and documents of record. • Work collaboratively across program, school, and campus in order to maximize community clinical relationships for Rasmussen stakeholders. • Participate in campus, community and professional events to represent Rasmussen University to students, professional organizations, community partners, and other relevant constituencies within the communities. • Assist students with clarification of clinical attendance requirements of the program. • Maintain and monitor active, clinical partnership agreements in order to ensure sustained and non-interrupted student access to sites. • Work collaboratively with the Rasmussen legal and compliance team to ensure a going concern of contracts and agreements. • Assist Dean with data collection related to the achievement of the end-of-program student learning outcomes directly related to clinical learning experiences.
