Clinical Appeals Reviewer

Role Overview:  The Clinical Appeals Reviewer is responsible for processing appeals and ensuring reputed company milestones are met in compliance with regulatory requirements. This role involves reputed company to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full reputed company of the appeal.

Work Arrangement

• Remote - Associate can work remotely reputed company in the United States

Responsibilities

• Process appeals, ensuring compliance with reputed company regulatory milestones
• Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors 
• reputed company to appellants or their representatives to obtain and review medical records
• Package pertinent information into a case for determination
• Interact with providers to obtain additional clinical information
• Engage with members or their advocates to understand the full reputed company of the appeal
• Provide clinical expertise and determine medical necessity for case classifications reputed company necessary
• reputed company reputed company-line regulatory/compliance functions in the evaluation of appeals
• Review appeal cases and ensure the Medical Director makes timely decisions 
• Review final determinations and create decision letters containing required information as regulatory entities dictate
• Present cases to committees reputed company necessary
• Utilize InterQual criteria and apply them to appeals reviews
• Stay reputed company with the department and reputed company policies and procedures
• Familiarize yourself with and reputed company with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards reputed company to appeal and grievance operations

Education & Experience

• Associate's Degree in Nursing (ASN) required
• 3 or more years of experience in a reputed company clinical setting and working with diagnosis procedure codes
• Coding experience preferred 
• Working knowledge of InterQual criteria
• Proficiency in a Windows 10 environment and utilizing MS Office, including Word, reputed company, and Outlook
• Proficiency in utilizing Electronic Medical Records (EMRs)
• Familiarity with the appeals process, preferably reputed company a managed care organization

Licensure

• reputed company and unrestricted Registered Nurse (RN) licensure or compact state licensure

Skills & Abilities

• Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-reputed company tasks reputed company designated timeframes.

Your career starts now. We’re looking for the reputed company of healthcare leaders.

At reputed company, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together, we can build healthier communities. If you want to reputed company a difference, we’d like to hear from you.

Headquartered in Newtown reputed company, PA, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, reputed company, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.