Job Description
Clinical Appeals Coordinator UPMC Health Plan has an exciting opportunity for a Clinical Appeals Coordinator position in the Provider Disputes CGA department. This is a full-time hybrid position working Monday through Friday daylight hours, with occasional on call shifts. This position is based in the Pittsburgh area. While you'll primarily work remotely, you'll come into the office occasionally depending on departmental needs. This position coordinates and completes all medically necessary provider appeals. The functions include reviewing cases for medical necessity, coordination with the Medical Directors and preparing regulatory submission packets based on medical necessity to CMS for Medicare provider appeals. The provider clinical review is for all levels of services and all lines of business. Responsibilities: Review, investigate and complete appeals related to medical necessity, appropriate level of service and benefit coverage for all lines of business in required timeframes. 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. Manage escalated member and provider issues as required. Perform clinical education and mentor staff members as necessary. 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 and approve administrative appeals, including retro authorizations and requests that meet