Clinical Review Clinician - Appeals

Summary:

• Work Mode: 100% Remote Nationally sourced. However, would like 1 candidate in AZ
• Shift: 8-5 EST or CST time zone-weekend rotation required
• Duration: 6 months, possible extension

Responsibilities:

• Perform clinical reviews for pre-service authorization denials and retrospective claim denials for members and providers
• Review case files, add, update, or edit authorizations
• Work closely with the MD team to make final decisions on cases
• Collaborate with supervisors and senior clinicians for support
• Engage in group chats on Teams for routine questions
• Process clinical reviews to ensure members have the best outcomes and access to necessary care
• Help reduce provider abrasion by processing retrospective claim reviews

Requirements:

• Education: Associate in nursing, Bachelors in nursing or higher
• Licensure: RN, LPN required; LVN preferred
• Must have Medicare knowledge, InterQual or Milliman Experience
• Experience in Clinical reviews for Utilization Management or Appeals
• Productivity expectations: Prime 7 CPD, iCP 9 CPD, CenPas 20 CPD cases per day with 95% quality

Preferred Skills:

• Medicare Appeals Experience