Job Description

Job Description

Job Description

The Clinical Appeals Reviewer is responsible for processing appeals and grievances, ensuring compliance with all milestones and regulations. This position involves outreaching to appellants or their representatives, reviewing medical records, interacting with providers, and ensuring a comprehensive case is developed for determination. The role also provides clinical expertise and may make determinations on medical necessity while ensuring regulatory and compliance standards are met.

Key Responsibilities:

• Outreach to appellants or their representatives to gather and review medical records and relevant information for case determination.
• Directly interact with providers to obtain additional clinical information, and engage with members or their advocates to understand the full scope of the appeal or grievance.
• Provide clinical expertise in evaluating medical necessity when required and serve as a front-line regulatory/compliance resource in reviewing appeals and grievances.
• Conduct thorough investigations for each case and prepare detailed Case Summaries for Medical Director review.
• Receive appeal or grievance cases and assign them to Medical Directors for medical determination.
• Review the final determination and draft decision letters, ensuring all regulatory requirements are included, and mail them within compliance timeframes.
• Utilize Interqual criteria for appeals and grievances reviews, ensuring the correct application of standards.
• Stay updated with department and CMS policies, ensuring compliance with federal, state, and local regulations, as well as other applicable regulatory requirements (e.g., CMS standards).

Required Qualifications:

• Experience: 3 or more years of experience in a related clinical setting.
• Education: Registered Nurse, with graduation from an accredited nursing program.
• Licensing: Current, unrestricted Registered Nurse license.

Preferred Qualifications:

• Familiarity with CMS policies and regulations related to appeals and grievances is preferred.
• Experience with Interqual criteria application in clinical reviews.

Certifications:

• Current, unrestricted Registered Nurse license required.

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