Clinical Appeals Consultant

ROLE AND RESPONSIBILITIES:

• Position in this function includes those responsible for management and administration of multiple Medical & Clinical Operations Functions, or managing general operations which are not specific to one of the functions in the Medical & Clinical Operations job family.
• Provides leadership to and is accountable for the performance of managers and/or senior level professional staff. Impact of work is most often at the operational or local business unit or market level.
• Owns an end-to-end process. Develops functional, market level, and/or site strategy, plans, production and/or organizational priorities. Identifies and resolves technical, operational and organizational problems outside own team. Product, service or process decisions are most likely to impact entire functions and/or customer accounts.
• Engage members over the phone to have a discussion about their health -Review available member service records and relevant documentation (e.g., utilization history, functional level, stratification information, current plan of care). Conduct comprehensive member assessment that includes bio-psychosocial, functional, and behavioral health needs. Utilize interviewing techniques and active listening to collect and retain member information and incorporating responses as they are presented to complete assessment