[New Job Opening] Appeals Clinician, Bright job Vacancy in Pune, Maharashtra


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Job Details:
Position Name :
Appeals Clinician, Bright
Pune, Maharashtra
Job ID :
Description : It’s Time For A Change…
Your Future Evolves Here
Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? Absolutely – about 40% in year-over-year revenue growth in 2018. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019, and one of the “50 Great Places to Work” in 2017 by Washingtonian. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.
What You’ll Be Doing:
Essential functions
Act as a member advocate addressing member or provider concerns
Analyze, preparing and support appeals and grievances review in compliance with state, federal and other regulatory requirements
Prepare appeals and grievances reviews and deliver to clinical staff in compliance with client, state, and regulatory required timeframes
Support appeals review for denied inpatient acute, post-acute, and outpatient services
Work with US-based appeals and grievance staff to coordinate documentation, decisions, and notifications of outcomes for various cases.
Research, investigate and summarize complex issues using state and federally mandated benefits, EOC/COC/SPD benefit language, Medical Policies and InterQual criteria
Prepare cases for Medical Director and/or External Review
Develop timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards
Formulate determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements
Recognize and report potential quality of care concerns
Utilize multiple internal and external computer applications and programs
Meet established productivity and quality standards
Perform other duties as assigned
The Experience You Need (Required):
Active, Medical Doctor, Doctor of Osteopathic Medicine, or equivalent license
Bachelor’s degree in a medical field
Minimum of 2 years of appeals experience in a payer-based environment
Minimum of 2 years of utilization management experience in a payer-based environment
Minimum of 3 years direct clinical patient care experience
Experience with clinical decision-making criteria sets (e.g. MCG, InterQual)
Excellent written and oral communication skills
Proficiency with PC-based software programs including Word, Excel and Outlook
Strong critical thinking, analytical, research and organizational skills
Ability to work remotely and independently
Basic knowledge and understanding of medical coding and claims processing
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