Clinical Review Clinician – Appeals

Clinical Review Clinician – Appeals

Requirements

• Active nursing license
• Experience in appeals and denials
• Background in utilization management and claims review
• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2 – 4 years of related experience

Responsibilities

• 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
• 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

Preferred Qualifications

• Knowledge of NCQA, Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred