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PacificSource Health Plans · 1 day ago

Appeals Clinician (Monday - Friday)

Bend, OR

Full-time

Onsite

Mid Level

$71K/yr - $106K/yr

3+ years exp

PacificSource Health Plans is dedicated to helping members access quality, affordable care. The Appeals Clinician is responsible for representing the clinical component of appeals, collaborating with various partners to ensure regulatory compliance and effectively advocating for member interests during the appeal process.

CommunitiesCustomer ServiceNon Profit

Responsibilities

Represent PacificSource Health Plans with external customers and maintain positive working relationships

Review appeal requests for appropriateness of care within established evidence-based criteria sets

Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines

Prepare case presentations for educational purposes and collaborative efforts with each LOB

Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments

Utilize Lean methodologies for continuous improvement. Utilize frequent huddles to monitor key performance indicators and identify improvement opportunities

Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy

Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources

Collect and interpret accurate claims data as needed for complete appeal review

Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc

Serve on designated committees, teams, and task groups, as directed

Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances

Meet department and company performance and attendance expectations

Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

Perform other duties as assigned

Qualification

Registered NurseBehavioral Health SpecialistMedical KnowledgeCase ManagementICDCPT CodesCollaborationCommunicationProblem SolvingTeamwork

Required

Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required

Registered Nurse or licensed behavior health specialist with current unrestricted state license

Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed

Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits

Understanding of contractual benefits and options available outside contractual benefits

Ability to use computerized systems for data recording and retrieval

Assures patient confidentiality, privacy, and health records security

Establishes and maintains relationships with community services and providers

Maintains current clinical knowledge base and certification

Ability to work independently with minimal supervision

Must be able to function as part of a collaborative, cohesive community

Preferred

Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred

Insurance industry experience helpful, but not required