Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Clinical Reviewer, Grievance & Appeals
🔍 New York, New York
Summary of Position
Perform clinical and administrative reviews within the Grievance and Appeals department, ensuring accurate administration of benefits, execution of clinical policy, timely access to appropriate levels of care and provision of payment for services that have already been rendered. Support the corporate and departmental goals and objectives.
Responsibilities:
• Prepare and present clinical summations/recommendations to the Medical Director or Pharmacist, or Independent Review Organization in accordance with state and federal regulations, NCQA requirements, and internal policy for final case determination in accordance with regulation and department policy.
• Research evidence-based guidelines, medical protocols, member benefit packages, provider networks, and on-line resources to review and investigate member and provider requests; determine appropriate utilization of benefits and/or claim adjudication. Consider quality initiatives and regulatory requirements as part of all case assessments.
• Under the direction of the leadership, is responsible for the execution of efficient departmental processes designed to manage utilization within the benefit plan. Responsible for the review of grievance and appeal cases referred for clinical and administrative pre-service, concurrent, and post-service appeal determinations; expedited and standard.
• Act as a clinical coordinator collaborating with members, providers, and facilities to evaluate member needs within the appropriate clinical setting, and as a clinical resource to the non-clinical Appeals staff.
• Enter and maintain documentation in the appropriate workflow tools meeting defined timeframes and performance standards (decision, notification, and effectuation).
• Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, NCQA and business standards. Effectively communicate verbally and in writing all decisions in an understandable, effective, timely and professional manner.
• Maintain an understanding of utilization management/grievance and appeals program objectives and design, implementation, management, monitoring, and reporting.
• Track and trend outcomes, analyzes data, and report on these to the Supervisor/Manager as required.
• Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager; report any quality of care or services issues or serious adverse events identified through the appeals process to the appropriate staff for investigation and processing.
• Assist with processing Department of Insurance Complaints related to medical necessity determinations; review and decide if a denied service or claim should be reversed or consult with the Medical Director in the decision-making process.
• Regular attendance is an essential function of the job. Perform other duties as assigned or required.
Qualifications:
• Bachelor’s Degree, preferably a BSN
• CPC preferred
• Active, unrestricted LPN or RN license
• 4 – 6+ years of relevant, professional, clinical experience required
• Managed care experience preferred
• Knowledge of Medicare, Medicaid and Commercial Product Lines preferred
• Knowledge of ICD-10 and CPT codes required
• Strong organizing and analytical skills; detail oriented, with ability to identify and resolve/escalate problems as needed required
• Ability to successfully manage multiple competing priorities and to meet deadlines required
• Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
• Strong communication skills (verbal, written, presentation, interpersonal) required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.