Organizational Determinations & Appeals Specialist

Organizational Determinations & Appeals Specialist

Regular

Exempt

GENERAL DESCRIPTION:

Receives, evaluates, and performs a thorough clinical analysis of pre-service requests and reconsiderations (appeals) received at MCS. Performs outreach for clinical information needed for final determinations and is effective in provider contacts.

ESSENTIAL FUNCTIONS:

Evaluate pre-service and appeals requests within the required timeframes according to applicable regulations and Company policies. Provide administrative support such as contacting insureds, providers, and contracted facilities via phone, fax, or e-mail to obtain clinical information necessary for evaluation and decision-making.

Apply critical thinking and clinical judgment to assess clinical guidelines, including InterQual, MCS Medical Policies, and Medicare Local Coverage Determinations (LCDs), to determine if additional clinical information is required for a final decision within the designated period.

Receive, review, and conduct comprehensive clinical analyses of reconsiderations (appeals) submitted to the Company.

Adhere to Line of Business (LOB) Advantage (ODAG) regulations, deadlines, outreach protocols, and other relevant regulatory requirements.

Assess changes in clinical urgency for expedited appeals and provide informed recommendations as appropriate.

Maintain accurate, thorough, and timely clinical documentation of all interventions, following operational guidelines and scenario-specific requirements.

Identify opportunities to support providers by offering guidance on portal user management (Provinet), fostering service partnerships, and providing clear instructions and alternatives for expedited information submission.

Recognize providers facing communication challenges or delays in submitting required information.

Conduct provider interventions to facilitate service closure following approval, minimizing pending clinical information requests through proactive outreach.

Recognize limitations and exclusions of benefits across various products or coverage groups.

Identify and refer vulnerable patients to case managers for inclusion in appropriate clinical programs.

Provide clinical support to Grievances and Appeals teams regarding Administrative Organization Determinations (AOD) requests.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.

May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree of Science in Nursing from an accredited institution. Minimum of two (2) years of experience in clinical areas.

Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required.

Other: N/A

Languages:

Spanish Intermediate (comprehensive, writing and verbal)

English Intermediate (comprehensive, writing and verbal)

"We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities."