You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking an experienced Appeals Manager to oversee utilization management activities and ensure compliance with regulatory guidelines. The role involves evaluating medical necessity, managing appeals, and ensuring cost-effective healthcare delivery.
Key Responsibilities
- Perform utilization management activities including hospital admission certification, continued stay review, and discharge planning.
- Evaluate medical necessity using evidence-based criteria and document all review findings.
- Oversee coordination and delivery of comprehensive healthcare services for members requiring care management.
- Interact with providers to approve care and address utilization management issues.
- Ensure all activities comply with regulatory agency requirements and participate in Medical Management grand rounds.
- Engage with external Clinical Peer Reviewers and designated External Review Agencies to ensure timely decisions and outcomes.
Qualifications
- New York State license as Registered Nurse, License Practical Nurse, or Physical Therapist.
- Strong knowledge of clinical guidelines such as InterQual or Milliman Care Guidelines.
Experience
- Minimum of two to five years of clinical experience in an acute or applicable care setting.
- Experience in appeals or UM/UR in a managed care or hospital setting is required.
Skills
- Excellent communication and interaction skills with providers and members.
- Proficiency in relevant medical management software and documentation systems.
- Ability to analyze utilization trends and identify potential needs.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
