Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote - Nationally sourced

Assignment Duration: 4 months

Work Schedule: 8-5 EST or CST time zone-weekend rotation required.

Work Arrangement: Remote

This is a part time role with 20 hour work weeks. When the schedule is agreed upon, they must work that schedule. They can work 5 days a week, 5 hours per day or they can work 3 days a week to hit their 20 hours. Example: if the candidate chooses MWF they cannot change it up after it is approve. It must remain consistent.

Position Summary:

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.

Background & Context: Shared Services Medicare Appeals department. Team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. These reviews determine if members can/did receive medically necessary services. Department is launching a BPO with expected team impacts. Resignations have come in and the need for this request is to mitigate staff leaving until BPO is up and running.

Key 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

Qualification & Experience:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• License/Certification:
  
  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