Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.

Conducts inpatient appeal reviews for members who have been discharged and/or are in an acute care facility (LTAC, INR, inpatient hospital) utilizing clinical judgement, approved criteria, medical record documentation, clinical practice guidelines, and member plan benefits. Responsible for clinically summarizing appeal cases for physician review rendering recommended decision based on criteria and all appeal related activities accurately, efficiently, and within mandated timeline requirements. Communicates the outcome of the appeals process with members, internal and external partners.

REPORTS TO: MANAGER APPEALS
DEPARTMENT: PHS - APPEALS
POSITION LOCATION: PHOENIX, ARIZONA 85008
JOB LEVEL: L10

Essential Functions:

• Uses critical thinking to determine if treatment plan is consistent with member's diagnosis and clinical needs. Ensures services provided are within benefit plan and that appropriate contracted providers are utilized.
• Completes complexed appeal case assessment to identify if member diagnosis meets medical necessity for admission into an acute care facility (LTAC, INR, inpatient hospital).
• Utilizes clinical judgement to access presenting systems and case documentation to make authorization decisions for medical necessity and assist the Medical Director with appeal determinations.
• Reviews medical record for medical necessity taking into account disease process, treatment plan, pharmacotherapy, and level of care. Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits.
• Based on medical record documentation, conducts discharge assessment to determine member readiness to transition to the next level of care.
• Uses critical thinking and clinical review skills to analyze medical chart documentation for expedited cases that impact the immediate care of members in an acute care facility.
• Applies regulatory requirements and accreditation standards to all review activity and reporting.
• Applies accepted criteria to review process, utilizes the parameters and inputs review data into systems.
• Produces approval and/or denial letters on behalf of the Medical Director for submission to member, provider or hospital.
• Ensures quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing.
• Ensures accurate data entry into the medical management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies.
• Performs special duties as assigned.

Additional Responsibilities:

Candidate Education:

• Required A High School or GED
• Preferred A Bachelor's Degree in nursing

Candidate Experience:

• Required 2 years of experience in an acute care clinical setting with general nursing exposure in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or case management with review.
• Preferred 2 years of experience in discharge planning
• Preferred 2 years of experience in Managed care experience

Candidate Skills:

• Intermediate Ability to create, review and interpret treatment plans
• Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
• Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
• Intermediate Knowledge of community, state and federal laws and resources

Licenses and Certifications:
A license in one of the following is required:

• Required Registered Nurse (RN)
• Required Other or LPN with 5 years of experience in acute care clinical setting

Technical Skills:

• Required Intermediate Microsoft Excel
• Required Intermediate Microsoft Outlook
• Required Intermediate Microsoft Word
• Required Beginner Microsoft PowerPoint
• Required Intermediate Healthcare Management Systems (Generic)

Languages:

All your information will be kept confidential according to EEO guidelines.