Utilization Review Clinician - Appeals

This role will require the successful candidate to work one of the following shifts: Monday to Friday, Noon to 9pm Eastern, OR Wednesday through Saturday, 10am to 9pm Eastern.

About the role

The Appeal Review Clinician is responsible for handling appeals cases and relevant information. The scope of this job may include handling health plan and Medicare Quality Improvement Organization (QIO) appeals, including expedited appeals, reconsiderations, and medical necessity reviews. This role ensures compliance with CMS regulations, organizational policies, and established clinical guidelines.

Responsibilities

• Review appeals submitted by members, providers, or authorized representatives related to denied authorizations, level of care determinations, or coverage issues.
• Classify appeals accurately once received.
• Ensure each appeal meets regulatory, contractual, and organizational filing requirements.
• Meet the required turnaround times to submit appeal packages to the QIO.
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth.
• Perform other job duties as assigned.

Requirements

• Bachelor's degree or equivalent work experience.
• 4-6 years of clinical nursing or therapy experience.
• Active RN, OT, or PT license.

Preferred Qualifications

• 1-2 years' experience in utilization review, case management, and/or managed care regulations.
• Experience with MCG Guidelines, InterQual, or other clinical decision support tools, especially in utilization management and prior authorization processes.

Job Expectations

• Willing to work additional or irregular hours as needed.
• Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Must be able to sit and view a computer screen for extended periods of time.

Benefits

• Excellent medical with Rx, dental, and vision benefits.
• Mental Health support through EAP.
• Generous paid time off, plus 13 paid holidays.
• 100% vested 401(K) retirement plans.
• Educational assistance up to $2500 per year.

Schedule

• Monday to Friday, Noon to 9pm Eastern, OR
• Wednesday through Saturday, 10am to 9pm Eastern.