• RN, UM Correspondence Coordinator

    Job Locations US-CA-Aliso Viejo
    Req No.
    2018-2341
    Category
    Clinical/Medical
    Type
    Regular Full-Time
  • Overview

    ABOUT CONCERTO HEALTH

    ConcertoHealth Inc. is the leading provider of specialized primary care and supporting clinical services for complex, frail, elderly, and dual-eligible patients. Operating exclusively in value-based agreements, ConcertoHealth provides high-touch, individualized care for patients, and deploys wraparound clinical resources to extend the reach of primary care practices. This comprehensive medical management solution, elevated by Concerto’s proprietary population health technology, improves overall healthcare quality and patient outcomes, benefitting payers and their provider networks.

     

    Concerto delivers comprehensive care to Medicare, Medicaid, and complex-needs patients.  The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. Our approach focuses on bringing harmony across the spectrum of a patient’s care, health, and dignity.

     

    The company is headquartered in Aliso Viejo, Ca. For more information, please visit: www.concertohealth.com

    JOB SUMMARY

     

    This position is responsible for the composition of written coverage determination letters that meet Medicare Rules or other UM guidelines, requirements of delegating health plan clients, and NCQA UM Accreditation standards.

    Responsibilities

    ESSENTIAL DUTIES AND RESPONSIBILITIES

     

    • Assists Senior Medical Director and Medical Director/Physician Advisor reviewers with the composition of written non-coverage determinations within required time frames
    • Ensures written non-coverage determinations are composed in plain language as described on plainlanguage.gov
    • Ensures non-coverage determinations include the specific reasons for the denial in easily understandable language; a reference to the guideline or criteria on which the decision was based; and, a statement that members can obtain a copy of the guideline or criteria on which the denial decision was based, upon request
    • Ensures non-coverage determinations include the rationale for the denial written in plain language that is easy for members to understand
    • Ensures non-coverage determinations are customized to each member’s specific circumstance
    • Communicates with external physicians and other providers to obtain additional information, if needed, for Medical Directors to make UM determinations
    • Identifies opportunities for improvement of UM processes and works collaboratively with key UM process owners to gain efficiency and increase productivity
    • Develops denial templates for tests, procedures, and equipment that comprise some of more frequently requested services and supplies.

    Qualifications

    QUALIFICATIONS

     

    • Registered Nurse
    • Experience writing non-coverage determination rationales for a cohort of managed Medicare members
    • 5 years medical-surgical clinical experience
    • 3 – 5 years recent experience with utilization and denial management in managed Medicare environment
    • 3 – 5 years recent experience in a Medicare managed care environment utilizing Medicare Local Coverage Determinations (LCD), Medicare National Coverage Determinations (NCD), and Milliman Care Guidelines (MCG)
    • Able to work in a fast-paced environment with multiple demands
    • Expert level of knowledge related to Medicare Rules and NCQA accreditation standards
    • Proficient with Microsoft products including Word, Excel, and PowerPoint
    • Excellent verbal and written communication skills
    • Excellent analytical and problem-solving skills
    • Experience with the use of QI tools to gain efficiencies and productivity with UM processes
    • Self-driven/directed
    • Performs other related duties as assigned

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