Appeals Independent Review Coordinator

Job ID: J141107
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 27, 2019

Share:

Description

General Overview:

This job owns the IRE (independent review) process for Medicare Appeals as part of the Appeals team. The incumbent gathers all necessary documentation required for the review and presents the package to the independent review committee. Gathering documentation could involve partnering with leaders, clinicians, and staff across multiple teams including Health Plan Operations and Legal.  Interacts with members of CMS and the independent review committee.  Writes medical case summaries requiring both legal analysis and medical justification based on relevant CMS laws and regulations, coverage determinations such as Local Coverage Determinations and National Coverage Determinations, and health plan policy as part of the process.

Essential Job Functions:

  • Gather documentation for the IRE (independent review) process.  This includes partnering across teams to obtain medical records that are associated with the case, reviewing notes from recorded calls and documentation submitted by the member.  It also involves pulling all of this documentation into the appropriate format required by the IRE.  
  • Develop medical case summaries requiring both legal analysis and medical justification based on relevant CMS laws and regulations, coverage determinations such as Local Coverage Determinations and National Coverage Determinations, and health plan policy to accompany the documentation provided to the independent review committee.  This could include summarizing the documentation gathered for the file, and finding the appropriate policies/LCDs, and speaking with the clinician(s) who made the decisions if necessary.
  • Other duties as assigned

Minimum Qualifications:

  • High School Diploma/GED
  • 3 -5 years of Legal experience
  • 3 - 5 years of Communications experience

Preferred

  • Bachelor's Degree in Communications Studies/Speech Communication and Rhetoric
  • 1 - 3 years of Appeals experience
  • 1 - 3 years of Health Insurance Industry experience
  • Paralegal Certificate

Referral Bonus: Level 1

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Summary

This job owns the IRE (independent review) process for Medicare Appeals as part of the Appeals team. The incumbent gathers all necessary documentation required for the review and presents the package to the independent review committee. Gathering documentation could involve partnering with leaders, clinicians, and staff across multiple teams including Health Plan Operations and Legal.  Interacts with members of CMS and the independent review committee.  Writes medical case summaries requiring both legal analysis and medical justification based on relevant CMS laws and regulations, coverage determinations such as Local Coverage Determinations and National Coverage Determinations, and health plan policy as part of the process.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

Stop Loss Claims Analyst

Home, PA, United States
Claims

Encounters Consultant

Pittsburgh, PA, United States
Claims

Enrollment Quality Coordinator

Pittsburgh, PA, United States
Claims

Appeals Independent Review Coordinator

Pittsburgh, PA, United States
Claims

Grievance and Appeals Analyst

Pittsburgh, PA, United States
Claims

Grievance and Appeals Analyst

Charleston, WV, United States
Claims

Grievance and Appeals Analyst

Camp Hill, PA, United States
Claims

Grievance and Appeals Analyst

Home, MA, United States
Claims

Grievance and Appeals Coordinator

Pittsburgh, PA, United States
Claims

Grievance and Appeals Coordinator

Camp Hill, PA, United States
Claims

Grievance and Appeals Coordinator

Charleston, WV, United States
Claims

Quality Analyst-5

Pittsburgh, PA, United States
Claims

OCR Specialist

Camp Hill, PA, United States
Claims

Senior Encounters Analyst-2

Pittsburgh, PA, United States
Claims