Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote - Nationally sourced.

Assignment Duration: 5 months; potential to extend

Work Schedule: 8-5 EST or CST; weekend rotation required. 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 approved. It must remain consistent.

Work Arrangement: Remote

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. We are a 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. Cases are assigned in round robin fashion. Nurses review case files, add, update or edit authorizations. Work closely with the MD team to make final decisions on cases. The clinical team works closely with their supervisors and senior clinicians on the team for support. Team does have group chats on Teams for routine questions. Team works closely together along with the coordinator team who owns end to end process on cases. Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.

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: