Job description

• Extrapolates and summarizes medical information for medical director, consultants and other external
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director as
• Ensures that appeals and grievances are resolved timely to meet regulatory
• Documents and logs appeal/grievance information on relevant tracking
• Utilize industry guidelines, Medicare Benefit Policy Manual guidelines, national coverage determinations, local coverage determinations, Interqual, and best practice standards, as well as a broad knowledge base and sound clinical judgment in reviewing medical records and writing
• Participate in telephonic Administrative Law Judge Hearings and present oral arguments as needed.
• Generates appropriate written correspondence to providers, members, and regulatory entities.
• Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written
• Identify potential quality of care issues within medical appeals; escalate as
• Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is
• Participate in departmental audits in preparation of regulatory site
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA's mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self- identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
• Complete required compliance training in a timely manner
• Review Code of Conduct at least annually and promote and enforce CCA's Code of Conduct Promote and enforce CCA's compliance program
• Adhere to CCA's Policy & Procedures
• Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy and/or security incidents; or any compliance concerns identified
• Ensure confidentiality of member and company proprietary information is maintained

• 3+ years of nursing experience in a Managed Care setting is required
• 5+ years of clinical nursing experience is strongly
• Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, and analytical
• Proficiency in Microsoft Word, Excel and Outlook.

• Strong interpersonal, verbal and written communication skills preferred
• Ability to work independently and make decisions
• Comfort working in a team-based environment
• Working knowledge of and ability to navigate through the healthcare system
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

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