Clinical Review Clinician, Appeals

Perform clinical reviews to resolve and process Medicare appeals by reviewing medical records and clinical data to determine medical necessity in accordance with policies, guidelines, and NCQA standards. Prepare case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards. Communicate with members, providers, facilities, and other departments regarding appeals requests. Generate appropriate appeals resolution communication and reporting. Partner with interdepartmental teams to improve clinical appeals processes and prevent recurrences based on industry best practices. Schedule is Wednesday–Sunday, 8am–5pm in your local time zone. Requires graduation from an accredited school of nursing or BSN, plus 2–4 years of related experience. Medicare Appeals experience required. Knowledge of NCQA, Medicare and Medicaid regulations and utilization management processes preferred. Active RN (state or compact), LPN/LVN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist required. Pay range: $27.02–$48.55/hour.