Appeals Res Analyst I

High School Diploma/GED required.
Requires a minimum of two (2) years utilization management or appeals experience.
Requires knowledge of health care delivery systems.
Requires knowledge of community resources.
Requires knowledge of CPT-4 and ICD-9 coding.
Requires knowledge of current Medical Management system.

Input and update demographic customer and clinical data for all utilization management programs and Continued Stay Review identifying eligibility via telephone and CRT prior to utilization.
Contribute to the maintenance of a competent staff by assisting with training new Analysts and Review Specialists etc. and assisting with monitoring post training performance to assure high quality performance.
Act as a resource for the Review Specialist providing appropriate guidance and coaching.
Compile and tabulate specific data on utilization management programs to monitor activity and make recommendations as needed.
Monitor the phone queue and make appropriate personnel adjustments to ensure that phone metrics are met.
Monitor queues to ensure that the Appeals are processed maintaining NCQA, State and DOBI requirements.
Monitor timeliness of appeal resolution and make appropriate daily assignment changes.
Assist in the completion of mandatory reporting inclusive of both internal and external reporting needs.
Assist in the development and implementation of workflows specific to the Appeals department.
Assist in performing staff audits as well as silent auditing of the phone queue.
Serve as the liaison for Medicaid Fair Hearings and ensuring compliance with continuation of benefits during the appeals process (Government Programs only).
Assist in the completion of Delegate Vendor Audits.