LOCATION: Remote – t his is a home based, virtual position. Candidate must reside in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Clinical Appeals Specialist RN is responsible for the clinical review, consultation and the generation of the Vaya Medicaid and State denial and appeals processes. This includes working with the Appeals Coordinator and Appeals Specialists in preparing Clinical Peer review referrals and Vaya notification letters to members/legal guardians and providers for reductions, suspensions, terminations or denials of services; providing support and information to members seeking to appeal a service request; action and facilitating the appeals process if requested; assist in monitoring and maintaining accurate appeals policies and procedures based on State and Federal regulations; and assist in maintaining/reporting weekly, monthly and quarterly Medicaid and non-Medicaid appeal statistics. This position also provides coordination and representation on behalf of Vaya during Mediation, State Fair Hearing Appeals, and DHHS Appeals of State-funded services processes. The Clinical Appeals Specialist RN reports to the Member Appeals Manager, works with other staff on the Member Appeals Team, will have dotted-line reporting to a medical doctor, and will work with other Vaya departments to report denial and appeal outcomes, and to ensure adherence to quality and accreditation standards. This position also performs additional duties as needed to support the appeals process in collaboration with the Utilization Management Department. This position may offer Remote Work Status.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

Essential Job Functions

Coordination of Vaya Medicaid and Non-Medicaid Denial and Appeals Processes:

Prepare and generate nonclinical and clinical peer review referrals, acknowledgment letters, service authorization and appeal decision letters.
During the appeal processes, contact members/ LRPs and providers to gather clinical documentation for review by individuals with the appropriate clinical expertise.
Consult with Vaya’s Utilization Management Team, Medical Team, Pharmacy Team, and/or upon request by the Legal Team, the applicable delegated subcontractor in preparation for mediated settlement conferences.
Represent, or assist in the representation of, Vaya in mediated settlement conferences concerning medical and pharmaceutical services authorization decisions;
Schedule, or assist the Appeals Coordinator in coordinating and scheduling, mediation preparation meetings and mediated settlement conferences, as well as other meetings relating to the appeals processes.
Respond to requests from the Legal Team for documentation related to authorization or appeal decisions.
Maintain a professional and collaborative working relationship with other staff on the Member Appeals Team, the Utilization Management Team, the Legal Team, and other internal and external persons for a shared goal of advancing the mission, vision, and values of the organization.
Answers and responds to the appeals telephone, fax, and email inquiries and to inquiries about the denial and appeal processes.
Assists members/ LRPs with filing oral and written appeal requests.
Uploads appeals and related documentation in Vaya’s administrative health record and other databases.
Provide support in conducting responsibilities in the appeals processes, including performing Personal Care Service appeal reviews, non-clinical appeals reviews, and administrative tasks (reviewing, auditing, logging, submitting, etc.) involved in the denial and appeal processes.
Support the work of the Appeals Specialists in generating such correspondence and the accompanying administrative tasks.
Support the work of the Appeals Team in maintaining appropriate electronic denials and appeals files.
Follow and track cases through all levels of the appeals processes, including at the plan-level, State Fair Hearing level, judicial review, and appellate level.
Maintain accuracy and maintenance of the Peer Review and the Denial and Appeal Logs.
Regularly communicates with the Utilization Management Team and delegated subcontractors on a daily basis concerning denial and appeal letter requests.
Assist Member and Recipient Appeals Manager in monitoring and auditing Appeals Team files.
Assist in implementing any corrective action plans as needed to improve denial and appeal processes.
Support the Member and Recipient Appeals Manager and Appeals Team in ensuring timely and accurate collection and reporting of data regarding denial and appeal process. This includes generation of notices in a timely manner, appeal rates, appeal outcomes, etc.
Assist with analysis of data, reporting of anomalies and generation of report outs.

Note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Knowledge, Skill & Abilities

A demonstrated clinical knowledge of MH, SU and/or I/DD Disabilities and diagnoses, co-occurring conditions, members with such disabilities and the associated services managed by Vaya.
Attention to detail, exceptional organizational, interpersonal, and writing skills, good judgment, and discretion on all aspects of work
Dynamic individual and strong team player who understands the position, respects boundaries, welcomes collaboration, searches for compromise, remains respectful, maintains a positive attitude, and demonstrates the ability to work harmoniously with a diverse workforce
Highly effective communication ability
Solution-focused and committed to self-accountability
Propensity to make prompt independent decisions based upon relevant facts and established policies, procedures, and business processes
Problem solving, negotiation and conflict resolution skills are essential to balance the needs of internal staff, members and their guardians and authorized representatives (including providers)
Flexible worker who readily accepts assigned tasks, adapts to unfamiliar situations, and searches for opportunity to help the team
Highly productive and motivated individual who takes pride in a job well done
Working knowledge, experience and familiarity with behavioral health and physical health conditions, diagnoses and related clinical and administrative documentation
Experience in data collection and analysis for technical report writing.
Proficient technology skills in Microsoft Office Suite such as Excel, PowerPoint, Teams and Word.
Mental flexibility and initiative in learning/teaching new technologies and methods to gain business efficiencies
Ability to prioritize competing deliverables and complete projects on time
Ability and comfort in adapting and adjusting to multiple demands, shifting priorities and rapid change.
Base knowledge of utilization management, authorizations and claims processing and payment concepts.
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and Vaya information system and Vaya-specific reporting systems is required.

Qualifications & Education Requirements

Bachelor’s degree in Nursing (Physical Health) with licensure as an RN. Two years of post-degree professional experience.

Licensure/Certification Required

Active RN Licensure in the State of North Carolina.

Preferred Experience

Knowledge and experience with Integrated Health and Managed Care preferred.

Physical Requirements

Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/ .

Vaya Health is an equal opportunity employer.

Vaya Health

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Clinical Appeals Specialist RN (Remote)