Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote - Nationally sourced (Preference for 2 candidates in AZ)

Assignment Duration: 6 months

Work Schedule: 8:00 AM - 5:00 PM EST or CST

Work Arrangement: Remote

Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on.

Cases are assigned in round robin fashion for staff to review and work.

The Organization's clinical team handles various types of authorization and claim review requests from various markets nationwide, processing clinical reviews to ensure members have the best outcomes and access to care needed.

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  Nurses review case files, add, update or edit authorizations.

  
  
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  Work closely with the MD team to make final decisions on cases.

  
  
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  Process clinical reviews to ensure members have access to care needed.

  
  
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  Help reduce provider abrasion by processing retrospective claim reviews.

  
  
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  Work closely with supervisors, senior clinicians, and the coordinator team on end-to-end case processes.

  
  
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  Participate in team collaboration via Teams group chats for routine questions.

  
  

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  Education/Certification (Required): Associate in nursing, Bachelor's in nursing or higher.

  
  
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  Licensure (Required): RN, LPN

  
  
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  Licensure (Preferred): LVN

  
  
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  Must haves:

  
  
  
  
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    Medicare knowledge

    
    
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    InterQual or Milliman Experience

    
    
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    Clinical reviews for Utilization Management or Appeals

    
    
  
  
  
  
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  Nice to haves:

  
  
  
  
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    Medicare Appeals Experience

    
    
  
  
  
  
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  Disqualifiers:

  
  
  
  
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    Not having a valid/active RN/LPN license

    
    
  
  
  
  
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  Performance indicators:

  
  
  
  
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    Productivity expectations vary based on platform.

    
    
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    Prime: 7 CPD

    
    
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    iCP: 9 CPD

    
    
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    CenPas: 20 CPD cases per day

    
    
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    95% quality on all cases

    
    
    
    
    
    
    

    Candidate Requirements
    Education/Certification	Required: Associate in nursing, Bachelor's in nursing or higher.	Preferred:
    Licensure	Required: RN, LPN	Preferred: LVN
    Years of experience required Disqualifiers Best vs. average Performance indicators	Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals Nice to haves: Medicare Appeals Experience Disqualifiers: Not having a valid/active RN/LPN license Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases Best vs. average: Productivity expectations are set based on platform.
    Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection	1	Utilization Management or Appeals review background (1 plus year)
    2	Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
    3	Retrospective claims clinical reviews (1 plus year)