Appeals Clinician

REPORTS TO: Manager, Physician Review Services
SUPERVISES: None

JOB SUMMARY: The Appeals Clinician is accountable and responsible for reviewing peer review outcomes and the quality management of same in accordance with Utilization Management policies and procedures. The position is accountable for ensuring all peer reviews meet all governance and client requirements in terms of content and medical relevancy as well as responsible for the tasks associated with completing a peer review. This position is very independent and the incumbent must be able to self-manage tasks and time based on defined turnaround times and client regulations.

MINIMUM QUALIFICATIONS:

Education: Registered Nurse, LCSW, LMHC, LMFT, PhD., or PsyD., with a current, unrestricted license.  BSN preferred.

Experience: One to two years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred.  One to two years directly related experience using InterQual criteria or healthcare criteria preferred.  Two (2) years experience in hospital-based nursing required.  Medical-surgical care experience preferred for positions in medical management areas.  Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred.

Knowledge/skills: Strong communication, documentation, clinical and critical thinking skills essential; Working knowledge of utilization management/case management preferred; Strong problem solving and decision making skills essential;  must be computer literate with fluency in Excel, Word and Access preferred

ACCOUNTABILITIES:

80%  Quality Management of Peer Reviews           

• Reviews all returning Peer Reviews ensuring all Quality Management standards are met. These standards include:
• Comprehensive Rationale that includes clinical criteria points
• Requests for Appeals from the Attending Physician are processed
• Appropriate documentation for additional research that may have been conducted is included  and referenced
• By processing system used, ensure all points of the review / appeal are accurately completed. This will require use of multiple systems

20%   Completion of the Review

• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
• Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
• Communicates all UM review outcomes in accordance with the health plan client profile procedures;
• Follows relevant client time frame standards for conducting and communicating UM review determination;
• Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures and in accordance with PRS Policies
• Identifies and communicates to the Director of Behavioral Utilization Management supervisor all potential quality of care concerns;
• Contacts, via fax, telephone and / or U.S. Mail the outcomes of Peer Reviews as directed by UM / PRS policy and procedures

Customer Services-Internal:

• Supports a positive working environment;
• Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing the Senior Director of Operations as a resource;
• Communicates to the Manager of PRS  all problems, issues and/or concerns as they arise;
• Communicates to the Manager of PRS any issues or concerns related to quality of care, using the Health Integrated procedure; 
• Maintains a courteous and professional attitude when working with all Health Integrated staff members and the management team; and
• Actively participates in team meetings, as designated.

Customer Service-External:

• Timely identifies and communicates to applicable practitioners, providers and the health purchaser staff all issues and concerns related to the case at hand;
• Communicates to the client/health plan staff any issues or concerns related to quality of care, using Health Integrated policies/procedures.
• Works, communicates and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated;
• Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and  
• Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), provider(s), patient/patient’s legally appointed representative any UM coverage determination(s).

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