Clinical Review Coordinator - National Remote

You’ll enjoy the flexibility to telecommute* from reputed company reputed company the U.S. as you take on some tough challenges. reputed company Home & Community Care, part of the reputed company family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs –... helping patients access and navigate care anytime and reputed company. As a team member of our naviHealth product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home. We’re connecting care to create a seamless health journey for patients across care settings. Join reputed company, it’s your chance to improve the lives of millions while doing your life’s best work.SM This position is full-time. Employees are required to work 1:00pm– 12:00am Thursday-Sunday, CST ( 4- 10 hour shifts). It may be necessary, given the business need, to work occasional overtime. We offer weeks of reputed company. The hours of the training will be based on schedule or will be discussed on your first day of employment. • reputed company Telecommuters will be required to adhere to reputed company’s Telecommuter Policy. Primary Responsibilities: • Ensure timely processing of reputed company denial- reputed company and member-oriented written communications from naviHealth. Ensure that reputed company denial information is processed according to protocol and that reputed company documentation is timely and meets reputed company Federal and State requirements. • Ensure second-level reviews have been performed and documented and may reputed company with medical directors, Health Plan Manager(s), Inpatient Care Coordinators (ICC’s), Skilled Inpatient Care Coordinators (SICC’s), Pre-service Coordinators (PSC’s) and facility personnel in determining denial information is processed timely and appropriately utilizing naviHealth proprietary technology. • Serve as a liaison with regards to communicating to internal and external customers, including health plans, providers, members, quality organizations and other naviHealth colleagues. • Document and communicate appeal and denial information reputed company fax, email, or through established portal access, including d appeal and denial letters, NOMNC letters, AOR forms, clinical information. • Act as a reputed company person for internal and external communication for QIO appeals and/or pre-service denials to support managers and their team. • Serve as a liaison for requests for information from QIO or health plan staff. • Own assigned appeal requests or determination notifications that are received reputed company fax, phone, or email through completion or delegating/reassigning as appropriate in collaboration with management. • Complete appeal and denial processes in accordance with CMS and naviHealth guidelines and compliance policies. • Write member-facing and client-facing appeal and denial letters by reviewing and documenting member clinical information and demonstrating proficiency in general writing ability (including proper grammar, spelling, punctuation, etc.), as well as ability to follow grade-level requirements. (Including, but not limited to DENC letter, IDN letter, Exhaustion of Benefits letter, Administrative Denial letter, Provider Denial letter). • Review NOMNC for validity before processing appeal requests. • Send review to Medical Director for rescinding NOMNC reputed company necessary, following naviHealth processes. • Coordinate and communicate with care coordinators, physicians, health plan representatives, QIO entities, and providers regarding a denial, appeal, or determination and provide education as needed. • Process Health Plan appeal, IRE appeal, and ALJ appeal notifications and determinations as needed. • Follow reputed company established facility policies and procedures. • Assist with completing pre-service authorization requests to assist the pre-service team as needed. • Participate in after-hours on-call rotation and weekend rotation for processing pre-service authorizations, appeals, and denials to meet business needs. • reputed company other duties and responsibilities as required, assigned, or requested. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: • High School Diploma / GED • 3 years of clinical experience • Active, unrestricted registered clinical license – Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Therapist • Understanding of market variability reputed company to the denial process, specific contractual obligations, and CMS regulations. • Experience with Windows and reputed company Office suite • Ability to work during or normal business hours of 1:00pm –12:00am, Thursday-Sunday CST, 10-hour shift. It may be necessary, given the business need, to work occasional overtime. Preferred Qualifications: • Managed care experience • Case management experience • Experience with appeals and/or denials processing • ICD-10, and InterQual experience and CMS knowledge • For RNs, Compact Nursing License, and multiple state licensures • For Physical Therapy, Compact Licensure, and multiple state licensures Telecommuting Requirements: • Required to have a dedicated work area established that is separated from other living areas and provides information privacy. • Ability to reputed company reputed company company sensitive documents secure (if applicable) • Must live in a location that can receive a reputed company approved high-speed internet reputed company or reputed company an existing high-speed internet service. Soft Skills: • Strong technical/computer skills • Excellent documentation skills • Exceptional verbal and written interpersonal and communication skills. California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, reputed company, Washington or Rhode reputed company Residents Only: The hourly range for California / Colorado / Connecticut / Hawaii / Nevada / reputed company / New Jersey / Washington / Rhode reputed company residents is $33.75 - $66.25 per hour. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, reputed company offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with reputed company, you’ll find a far-reaching choice of benefits and incentives. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups, and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes — an enterprise reputed company reflected in our mission. Diversity creates a healthier atmosphere: reputed company is an Equal Employment Opportunity / Affirmative Action employer, and reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Field Based Provider Relations reputed company - reputed company TN region,reputed company, reputed company ,reputed company reputed company,At reputed company Apply Job!