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Company

The Cigna Group · 18 hours ago

Case Management Analyst

Nashville, TN

Full-time

Remote

Mid Level

3+ years exp

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Responsibilities

Communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions

Coordinate and perform all appeal related duties in a Medicare Advantage Plan

Analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication

Researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal

Provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations

Reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately

Prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution

Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part C

Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal

Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines

Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denied

Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal

Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director

Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response

Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.

Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)

Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance

Adhere to department workflows, desktop procedures, and policies

Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals

Read Medicare guidance documents report and summarize required changes to all levels department management and staff

Support the implementation of new process as needed

Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers

Understand and investigate billing issues, claims and other plan benefit information

Assist with monitoring, inquiries, and audit activities as needed

Additional duties as assigned

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Medicare AppealsUtilization Case ManagementMedicare Part CMedicaid regulationsMicrosoft OfficeHIPAA guidelinesCMS guidelinesICD9ICD10

Required

Unencumbered LPN/LVN licensure in state of residence

3-5 years’ experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service

Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10

Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.

Must have the ability to work objectively and provide fact based answers with clear and concise documentation.

Proficient in Microsoft Office products (Access, Excel, Power Point, Word).

Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.

Ability to multi-task and meet multiple competing deadlines.

Ability to work independently and under pressure.

Attention to detail and critical thinking skills.

Requires High-Speed Broadband Wired Internet