Clinical Appeals Coord

Health Net, Inc. (NYSE: HNT) is among the nation's largest publicly traded managed health care companies. Health Net's mission is to help people be healthy, secure and comfortable. The company's POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company's Web site at www.healthnet.com

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JOB SUMMARY:

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The Clinical Appeals Coordinator reports to the Manager of Grievances & Appeals, or the Manager of Clinical Appeals and is responsible for investigating and responding to medical necessity appeal and administrative grievance requests.

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ESSENTIAL DUTIES AND RESPONSIBILITIES: Researches, investigates, resolves, and documents medical necessity appeal requests in accordance with company and government regulations, including determining eligibility for coverage and communication with provider and member when applicable.Reviews appeal and grievance cases with PHS Medical Directors and external specialty consultants. This requires an in-depth understanding of the basis for our denial, the standard of care, and the clinical implications of our position. Additionally, it requires the ability to articulate the nuances of both positions in order to ensure that all points of view are taken into consideration.Maintains comprehensive knowledge of all Northeast Region products (excluding Medicare). Maintains a comprehensive knowledge of departmental and company policies, procedures, and services including departmental processes of Operations, Medical Management, Customer Service, Sales and Marketing, Government Programs, Network Management, and the regional offices.Achieves turnaround time for medical necessity appeals as mandated by company policy and government regulations.On a rotating basis with other staff, maintains responsibility for expedited cases received over the weekend. This responsibility includes carrying a beeper and being prepared to come into the office, if necessary.Performs investigations for inquiries from regulatory bodies.Empowered to make final determinations on clinical reconsideration up to a specified dollar amount.Acts as primary liaison with Medical Directors to investigate and resolve assigned appeals.Activates and completes any medical authorizations relating to appeals and grievances, when applicable.Assists with training new staff.Assists Manager of Clinical Appeals or the Manager of Grievances & Appeals in tracking and trending member appeals.Develops policies and procedures at the discretion of the Manager.Provides recommendations to Manager of Clinical Appeals/Manager of Grievances & Appeals, to enhance member materials that describe plan benefits and administration.Provides support on special projects and performs other duties as needed.



REQUIREMENTS:

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Education:

Current LPN degree or related clinical degree is required; RN degree is preferred.

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Certification/License:

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Experience:Minimum three years clinical experience in a health care delivery system is required. Previous experience in a health maintenance organization is desirable.

Knowledge, Skills & Abilities:Ability to work in an innovative health care delivery system and a belief in the HMO philosophy of delivering managed health care is desirable. Demonstrates a high level of interpersonal, negotiating, and written communication skills. Ability to independently problem-solve and interact professionally with members, providers, and staff is necessary. Basic PC skills, preferably in a Windows environment, are necessary. Knowledge of CPT coding and ICD coding is required.

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Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

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Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

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Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.