Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote (nationally sourced, preference for 1 candidate in AZ)

Assignment Duration: 6 months (Possibility to extend or convert)

Position Summary:

Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Background & Context:

Shared Services Medicare Appeals department. Team performs clinical reviews for pre-service authorization denials as well as retrospective claim denials.

Key Responsibilities:

* Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal

* Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards

* Communicates with members, providers, facilities, and other departments regarding appeals requests

Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards

* Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests

* Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

* Knowledge of NCQA, Medicare and Medicaid regulations preferred.

* Knowledge of utilization management processes preferred.

* Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals

License/Certification:

LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required

Working Conditions & Physical Demands (If Applicable): 8-5 EST or CST time zone-weekend rotation required.

Additional Information (If Applicable): Productivity expectations vary by platform (Prime 7 CPD, iCP 9 CPD, CenPas 20 CPD cases per day with 95% quality).