Works with Registered Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and determination. Performs clinical review of medical records related to grievances and appeals. Responsible for handling member and provider appeals providing clinical reviews and write-ups and recommendations, mailing and faxing of resolution letters.
Reviews grievance cases that require immediate clinical quality of care, initial coding of member grievance and evaluation and/or require immediate pre-service authorization evaluation.
Investigates Provider Disputes/PDR and prepares clinical summary for Medical Director determination.
Work with the external providers and PPGs representatives to obtain relevant medical records and communication documentation.
Investigation and preparation of State Fair Hearing cases as assigned.
Prepare resolved complaint files for Centers for Medicare and Medicaid Services(CMS), external review organization (QIO or IRE).
Work with Utilization Management and PNO to facilitate completion of resolution determination.
Investigate, prepare summary and work with Medical Directors to resolve expedited cases within regulatory timelines. Maintain knowledge of regulatory changes related to all grievances and appeals and meets regulatory requirements. Refers cases for further follow-up or notification as appropriate, e.g. fraud and abuse cases shall be forwarded to Compliance Department.
Perform other duties as assigned.