Clinical Appeals Reviewer

Role Overview

The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and engaging with members or their advocates to understand the full intent of the appeal.

Responsibilities

• Process appeals, ensuring compliance with all regulatory milestones
• Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors
• Outreach to appellants or their representatives to obtain and review medical records
• Package pertinent information into a case for determination
• Interact with providers to obtain additional clinical information
• Engage with members or their advocates to understand the full intent of the appeal
• Provide clinical expertise and determine medical necessity for case classifications when necessary
• Perform front-line regulatory/compliance functions in the evaluation of appeals
• Review appeal cases and ensure the Medical Director makes timely decisions
• Create decision letters containing required information as regulatory entities dictate
• Present cases to committees when necessary
• Utilize InterQual criteria and apply them to appeals reviews
• Stay current with the department and AmeriHealth Caritas policies and procedures
• Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations

Requirements

Associate's Degree in Nursing (ASN) required
3 or more years of experience in a related clinical setting and working with diagnosis procedure codes
Coding experience preferred
Working knowledge of InterQual criteria
Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook
Proficiency in utilizing Electronic Medical Records (EMRs)
Familiarity with the appeals process, preferably within a managed care organization

Qualifications

Licensure: Current and unrestricted Registered Nurse (RN) licensure or compact state licensure

Skills & Abilities

• Strong verbal and written communication
• Critical thinking
• Presentation
• The ability to manage and complete multiple high-priority tasks within designated timeframes

Benefits

Our Comprehensive Benefits Package includes:

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement and more.