► CareersUtilization Management and Appeals Clinician

Utilization Management and Appeals Clinician

Minuteman Health is seeking a Utilization Management and Appeals Clinician. Under the supervision of the VP of Quality and Medical Management, this position is responsible for monitoring member utilization, various medical management functions, and assisting in the review, response and tracking of member and provider complaints and appeals.

Responsibilities:

  • Collaborate with MHI third party administrators, the medical management team and the provider contracting team to service members in need of UM, CM and DM Services.
  • Work with provider contracting team to implement, track and evaluate outcomes of members receiving CM and DM services from providers.
  • Participate in MHI appeals, grievance and quality of care complaints process.
  • Review, research, and document clinical appeals and complaints with the Grievance and Appeals Manager and the Chief Medical Officer.
  • Direct members to appropriate site of services of urgent care needs.
  • Support UM Oversight Program, Quality Improvement Program, and NCQA compliance.
  • Conduct care coordination activities in conjunction with the TPAs as needed.
  • Other duties as assigned.

Qualifications:
  • Registered Nurse (R.N.) license in MA or NH
  • Bachelor of Science in Nursing (B.S.N.) or related field
  • 3 – 5 years of clinical nursing experience minimum
  • Prior experience in a managed care or health insurance environment
  • Prior experience in Appeals, Care Management or Utilization Management preferred
  • Excellent communication skills and attention to detail
  • Experience working with third party administrators and vendors

Description of Company:
 

Minuteman Health is a new, non-profit health insurance option for Massachusetts and New Hampshire residents. Founded by contributors that include Tufts Medical Center, Vanguard Health Systems and New England Quality Care Alliance (NEQCA), Minuteman offers consumers and employers lower-cost high-quality care with unprecedented transparency, as well as increased efficiency and satisfaction for physicians, patients, and employers alike.


*Please, NO recruiters or agencies


 


 



Accessibility: If you need an accommodation as part of the employment process please contact Human Resources at Email: careers@minutemanhealth.org

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