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Appeals & Grievances Clinical Letter Writer in Coral Gables, FL at Beacon Health Options

Date Posted: 1/25/2019

Job Snapshot

Job Description

About the Position:

Beacon Health Options is currently seeking a dynamic Appeals & Grievances Clinical Letter Writer to join our team in Coral Gables, FL! The Clinical Letter Writer is responsible for reviewing adverse determination decisions against criteria and policy, escalating questions to the physician reviewer, and creating letters that meet regulatory and Plain Language requirements. This position requires a person who can synthesize various clinical and administrative requirements, communicate well with the team and clients, and write clearly.

The Clinical Letter Writer is responsible to create adverse determination notifications that meet all accreditation, State, regulatory and Federal criteria. The letter writer uses plain language and good written skills to clearly communicate adverse decisions to both members and providers while working with internal and external staff to ensure that decisions are made, documented and communicated clearly. The incumbent identifies and refers quality and/or clinical issues to the Manager of Quality - Appeals or Medical Director.

The Clinical Letter Writer appropriately identifies potential cases for Case Management programs and communicates appropriate information to other staff members as necessary/required. The incumbent participates in continuing education initiatives and collaborates with Claims, Quality Management and Provider Relations Departments as requested while performing other duties as assigned.

Position Responsibilities:

Clinical Letter Notifications

  • Reviews adverse determinations against criteria and medical policies and works with the physician reviewer to monitor the adverse determination process and ensure notification timeframes are met.
  • Creates adverse determination notifications that meet all accreditation, State, regulatory and Federal criteria. Uses plain language and good written skills to clearly communicate adverse decisions to both members and providers

System Documentation

  • Appropriately identifies and refers quality and/or clinical issues to Director of Appeals or Medical Director.
  • Appropriately identifies potential cases for Case Management programs.
  • Communicates appropriate information to other staff members as necessary/required.
  • Clearly documents appropriate information in the database system.

Customer Service

  • Interface with internal and external customers to ensure that decisions are made, documented and communicated clearly. 
  • Maintain telephone superior service standards. 
  • Contribute to weekly staff meetings and clinical conferences. 
  • Attend appropriate meetings, trainings and conference calls as scheduled. 
  • Conduct business in a professional manner. 
  • Troubleshoot clinical issues. 
  • Investigate and research to resolve customer complaint problems and issues.    

Professional Standards

  • Apply Beacon Health Options policies and procedures consistently.
  • Maintain confidentiality of Clients, Business Records and Reports. 
  • Maintain ethical and professional standards. 
  • Maintain individual productivity and performance standards. 
  • Meet Departmental expectations, accuracy, and productivity and performance standards.
  • Support Beacon Health Options in achieving Mission Statement. 
  • Complete tasks accurately and within required timeframes. 
  • Adhere to the components of the Compliance Program. 
  • Ensure that job tasks are performed in a legal and ethical manner. 
  • Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline.
  • Adhere to compliance training requirements and understand that training is a required condition of employment.   

Position Requirements:

  • Education: Bachelor Degree in social work or psychology or a Bachelor’s level mental health counselor or related field or degree required
  • Relevant Work Experience:  3 years’ experience in psychiatric or substance abuse treatment with experience in settings that include inpatient, partial, and/or outpatient care OR 5 years’ experience in a behavioral healthcare insurance field such as Clinical Appeals, Quality Management or Clinical Care Management preferred
  • Licensures: Current, valid and unrestricted license in a State or territory of the United States in a mental health field (RN, Ph.D., LICSW/ACSW, LLP, MHC, LPC, etc.) preferred
  • Knowledge, Skills, & Abilities:
    • Experience with clinical decision-making criteria: sets such as American Society of Addiction Medicine (ASAM)  or LOCADTR Criteria
    • Must possess the ability to function in an interdisciplinary setting
    • Must have knowledge and experience using management information systems
    • Strong customer service orientation and excellent written and verbal communication skills require
    • Must be knowledgeable about care resources and levels of care availability

To Apply:

Click below on “Apply for this Position” to create a profile and apply for the position

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment.  EOE/AA/M/F/Veterans/Disabled

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