Clinical Review Clinician - Appeals

Position Purpose

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.

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 consistency, efficiency, and appropriateness of responses of all appeals requests
• PARTNERS WITH INTERDEPARTMENTAL TEAMS TO IMPROVE CLINICAL APPEALS PROCESSES AND PROCEDURES TO PREVENT RECURRANCES BASED ON INDUSTRY BEST PRACTICES
• PERFORMS OTHER DUTIES AS ASSIGNED

Required Education/Experience

• Requires Graduate from an Accredited School of Nursing OR
• Master's degree in related Behavioral/Counseling field AND minimum of 2 – 4 years of related experience

Preferred Experience

• 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred.
• Direct work experience with clinical data, clinical review, and specifically the APPEALS process and procedures preferred.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of Utilization Management principles and processes preferred

Licenses/Certifications

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

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Qualifications

• Complies with all policies and standards
• Strong communication, attention to detail, organizational and time management skills
• Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g. instant messaging, email, video conferencing, digital phone)
• Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams)