Clinical Review Clinician - Appeals

About the role

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. This is a remote position. Hours are M-F 8:00 am-5:00 pm CST, with weekend on-call rotations and a holiday rotation. Behavioral health experience strongly preferred.

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

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 – 4 years of related experience
• Knowledge of NCQA, Medicare and Medicaid regulations preferred
• Knowledge of utilization management processes preferred

Licenses/Certifications

• 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

Pay

$27.02 - $48.55 per hour

Benefits

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