Ref No.: 16-00032
Location: Pittsburgh, Pennsylvania
Start Date: 01/06/2016
Aequor Healthcare Services is looking for an RN for Case Management in the Pittsburgh, PA area.

Job Description or Additional Skills: This position coordinates and completes all medically necessary provider appeals. The provider clinical review is for all levels of services and all lines of business.

Interpret Medical Director notes and summarize into correspondence for provider and/or facility. Manage escalated provider issues as required. Prepare comprehensive Independent Review Entity Packets, including clinical justification of the Medical Director's decision which includes all applicable points from the specific policy, Evidence of Coverage statement and/or documentation submitted to which the decision pertains. Respond to providers in writing with the results of appeal review in accordance with Complaints and Grievances Department standards and all applicable regulatory requirements. Outreach to providers as appropriate to communicate decision.
Review and approve Administrative appeals, including retro authorizations and requests that meet medical criteria. (i.e. private duty nursing, DME, behavioral health, experimental and investigational, potential benefit exceptions, cases requiring prior authorization, etc. ) Review and investigate appeals from providers where decisions by the health plan Special Investigation Unit audit process have impacted reimbursement. Determine uphold or overturn of decision.

Review first and second level appeals for medical necessity, completes a comprehensive medical necessity packet summarizing clinical facts for the Medical Director review. Coordinates timely case review by a Health Plan Medical Director.

Review, investigate and complete appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes.

Track and trend appeals related to medical necessity, coding issues and other administrative reasons.

Work closely with Special Investigations Unit (SIU), Network Development, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, Benefit Configuration, Compliance, Enrollment, Pharmacy Services, Reimbursement and Coding departments to ensure review processes are understood and meet Health Plan strategy for appropriateness of provider reimbursement as well as quality of care and services.

Dates: 1/4/2016 - 4/4/2016

Shift Days: Monday, Tuesday, Wednesday, Thursday, Friday
Shift Start/End Times: 08:00 AM - 04:30 PM 

If you are interested please call Gina @ 814-935-7084 and/or submit your resume to