Care Manager-Appeals & Grievances (Shelton, CT)

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY: 

 

The Appeals and Grievances Care Manager performs advanced and complicated case reviews to assess the appropriateness of medical care and services provided to members. Position incumbent holds authority to overturn determinations following established guidelines and applying considerable clinical judgment, independent analysis, and detailed knowledge of managed health care, departmental procedures and clinical guidelines. Position incumbents also identify system issues that could compromise proper care or service.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES: Conducts clinical review and evaluation of member appeals and grievances. Applies clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans to evaluate the appropriateness of care. Reviews, triages and prioritizes cases. Expedites referrals appropriately, and/or follows expedited process to resolve appeal or grievance. Serves as an advocate, addressing member or concerns. Researches and analyzes complex issues, acquires and reviews case documentation against clinical records, clinical guidelines, policies, Benefit Agreement, Benefit Policy and coding guidelines. Summarizes cases including articulating member’s perception, initial denial determination and notification, medical records analysis, and applicable policies, guidelines, benefit plans, and laws, rules and regulations. Effectively applies, interprets and communicates policies, procedures, clinical guidelines, medical policy, regulations and standards. Prepares questions for consultant review or external third party medical review. Develops determination recommendations that resolve member disputes consistent with regulatory and accrediting agencies’ requirements, and health plan objectives. Presents cases to Medical Director and/or supervisor for review or determinations. Prepares reports, data or other materials for committee presentation. Develops and/or reviews determination documentation and correspondence, assuring accuracy, completeness and conformance to standards. Interacts with the member and/or A&G staff to ensure resolution of plan recommendations. Assures communication of member rights. Documents and records activities appropriately. Recognizes and refers potential quality care concerns. Prepares clinical summaries and assists legal department with litigation research. Identifies and communicates system improvements or individual care issues that could cause failure to provide appropriate care or meet service expectations. Reports suspected fraud and abuse as required by company policy. Maintains confidentiality of all information in compliance with state and federal law and Health Net Policy.

REQUIREMENTS:

 

Education:
Graduate of an accredited nursing program; Bachelor’s Degree preferred

 

Certification/License:Valid & Active Registered Nurse State of Connecticut Licensure required.

Experience:Minimum three years clinical experience requiredThree to five year’s utilization management or quality management experience strongly preferredPrevious experience in appeals and grievance casework required

Knowledge, Skills & Abilities:Strong knowledge of accreditation, federal and state regulations/requirementsKnowledge of risk management principlesStrong analytical and problem solving skillsExcellent oral and written communications skillsExcellent organizational, case preparation and abstracting skillsTeam player who builds effective working relationshipsProven ability to work independentlyKnowledge of standardized clinical guidelines and InterQual, preferredMedical coding knowledgeSkill to operate PC-based tools including word processing and spreadsheetsAbility to effectively analyze, interpret, apply and communicate policies, procedures and regulations


OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.


Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.