Appeals & Policy Nurse

Position Summary

The Appeals and Policy Nurse position will manage the development and maintenance of clinical policies as well as conduct a comprehensive analytic review of medical records utilizing clinical researched evidence and follow regulatory requirements to perform appeal reviews. This position requires subject matter expertise and proficiency in understanding of the concepts, features, benefits, disclosures of regulatory provisions for HMO's and of government health insurance programs for Medicare Advantage and Medicaid to ensure recommendations are compliant with regulatory entities. As a subject matter expert in policy development and appeal reviews the Appeals and Policy Nurse will act as resource for Provider Relations, Member Services and the Claims department. It is the expectation the Appeals and Policy Nurse will identify issues for potential trainings with Health Services staff and presentations with other stakeholders of Health New England. The Appeals and Policy Nurse is required to attend the Medical Technology Assessment Committee (MTAC) the Clinical Policy Oversight Committee(CPOC and the Clinical Care Assessment Committee (CCAC) Ensure compliance with HIPAA regulations to include confidentiality. Awareness of NCQA, DOI, CMS and EOHSS regulations

Member Appeals 20%

• Investigate, analyze, research and respond to member complaints and appeals directed to the Health Services Department in a timely and thorough manner and in accordance with departmental policies and procedures.
• Utilize pre-existing criteria sets and/or clinical evidence from existing research sites
• Determine if appeal meets clinical or medical necessity criteria for expedited appeal process
• Communicate and coordinate with C&A staff and other appropriate departments for collection of information
• Prepare the appropriate written response /recommendation to C&A based on supporting clinical evidence
• Respond to member complaints/appeals within NCQA, CMS, DOI and EOHHS time frames
• Ensure that decisions and authorizations are appropriately effectuated by coordinating with Health Services and/or Claims Department
• Prepare convincing appeal arguments using pre-existing criteria sets and or clinical evidence to Participate in Office of Patient Protection and Self-Funded Independent Review Entity external review as requested by C&A
• for additional levels of CMS appeals: e.g. Medicare Advisory Council, Administrative Law Judge ("ALF") hearings, etc.

Provider Appeals 35%

• Investigate, analyze, research and respond to Provider appeals directed to the Health Services Department in a timely and thorough manner and in accordance with departmental policies and procedures.
• Utilize pre-existing clinical criteria sets and/or clinical evidence from existing research sites
• Proficiently read and understand abstract information from handwritten patient medical records
• Review provider appeal process with stakeholders to minimize invalid appeals
• Communicate and coordinate with Provider Appeal staff and other appropriate departments for collection of sufficient clinical information
• Decide the appeal in accordance with department guidelines
• Prepare the appropriate written response /recommendation to Provider Appeals
• Respond to appeals within NCQA, CMS, DOI and EOHHS time frames
• Assist with creating standards for the review process
• Assist with creating criteria for appeals for the Provider Appeal staff to utilize
• Act as a resource for Provider Appeals clinical/non-clinical questions
• Review 2nd level appeals to determine if the attached information is new or different

Policy Writing 30%

• Develop departmental policy using an integrated approach to include regulatory requirements ( DOI, CMS. EOHHS and NCQA)
• Develop and maintain documented standard operation procedures (SOP) in accordance with organizational and regulatory requirements
• Ensure consistency with method, style, design and terminology
• Proficiently read and understand abstract information from handwritten patient medical records
• Follow corporate standard and requirements
• Interact with other subject matter experts (SMEs) in all business areas to ensure policy and procedures are comprehensive, complete and accurate
• Create, review, revise/update, activate and archive policies
• Research national standards of coverage, Peer review articles and evidence based medicine recommendations
• Identify procedural inconsistencies and inefficiencies
• Assess and confirm interpretation of new and/or changing policy
• Monitor effectiveness of existing policy and procedure documentation, ensuring staff is aware of changes
• Ensure the review, revision, editing and finalized document is posted for use
• Present new and existing updated policies at the Clinical Care Assessment Committee (CCAC) and Clinical Policy Oversight Committee(CPOC)

Miscellaneous: 15%

• Assist with Prior authorization reviews, projects and initiatives as assigned.
• Attend Clinical and Payment Policy Oversight Committee (CPPOC) and Medical Technology Assessment Committee (MTAC)
• Awareness of current coding issues and changes
• Review medical coding trend and identify potential training needs
• Collaborate with team leads/supervisors on department and training materials

Minimum Requirements:

Bachelor's degree with a current Registered Nurse license and 3-5 year experience with health insurance policy writing and experience with complaints and appeals preferably in an HMO; or an equivalent combination of education and experience.

• Experience with Medicare and Medicaid preferred
• Coding experience preferred
• Excellent verbal and written communication skills willingness to deliver presentations
• Excellent critical thinking and organizational skills with attention to detail
• Excellent time management skills and the ability to manage multiple priorities
• Intermediate skill level with Word
• Beginner skill level with Excel
• Sound clinical assessment and decision-making skills and highly ethical
• Ability to navigate through computer systems
• Ability to research for supporting evidence
• Able to work in a fast paced environment
• Ability to successfully work independently and to adapt to changing priorities and regulations