**Must have at least 2 years of CM experience in a hospital setting**
The Appeals and Denial Coordinator will be responsible for reviewing adverse determination decisions against criteria and policy, escalating questions to the physician reviewer, and creating letters that meet regulatory and Plain Language requirements.
o Reviews adverse determinations against criteria and medical policies and works with the physician reviewer to monitor the adverse determination process and ensure notification timeframes are met. Creates adverse determination notifications that meet all accreditation, State, regulatory and Federal criteria. Uses plain language and good written skills to clearly communicate adverse decisions to both members and providers
o Appropriately identifies and refers quality and/or clinical issues to management of Appeals or Medical Director. Appropriately identifies potential cases for Case Management programs. Communicates appropriate information to other staff members as necessary/required. Clearly documents appropriate information in the database system.
o Interface with internal and external customers to ensure that decisions are made, documented and communicated clearly.Maintain telephone superior service standards.Contribute to weekly staff meetings and clinical conferences.Attend appropriate meetings, trainings and conference calls as scheduled.Conduct business in a professional manner.Troubleshoot clinical issues.Investigate and research to resolve customer complaint problems and issues
AMN Healthcare company, is an EEO/AA/Disability/Protected Veteran Employer. We encourage minority and female applicants to apply