Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote in Ohio - Columbus area preferred

Assignment Duration: 6 months

Work Schedule: 8 am-5 pm

Position Summary:

* Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services following policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Background & Context:

* Cohesive; works closely together (including with Sups) to ensure any assistance needed

* 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.

* Additional need

Key Responsibilities:

* Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system).

* Behavior and accountability and ability to pivot when new priorities come up

* Emails and Team chats to ensure communication is reached and assistance is available, if needed

Qualification & Experience:

* Required: LPN Minimum

* Preferred: RN-Not required

* Nice to have:

- Direct patient care experience

- Longevity at positions

- Writing appeal or authorization outcome letters.

- experience with Trucare and/or Amisys systems is greatly valued.

- Utilization review nurse, appeal review nurse and direct patient care experience.

* Performance indicators: (Metrics: 10 to 15 appeals a day after training. Not letting any items in work queues go over compliance Turn Around Time.)

* Best vs. average:

1. 
   

   Experience with Utilization Review/Management-2 yrs

   
   
2. 
   

   Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case.

   
   
3. 
   

   Review medical code data and records to determine whether a denial is warranted.

   
   
4. 
   

   Utilizing multiple appeals/claims systems to conduct medical reviews.

   
   
5. 
   

   Comfortable with Microsoft office programs and utilizing systems to input medical criteria.