Clinical Review Clinician - Appeals - Remote

Overview

This position involves performing clinical reviews to resolve and process appeals by analyzing medical records and clinical data in accordance with established guidelines.

In Short

• Perform clinical reviews for appeals processing.
• Review medical records and clinical data for medical necessity.
• Prepare case reviews for Medical Directors.
• Ensure timely processing of appeals in compliance with standards.
• Communicate with members and providers regarding appeals.
• Generate appeals resolution communication.
• Work with leadership to improve appeals processes.
• Comply with all policies and standards.
• Requires a nursing degree and relevant experience.
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred.

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2 – 4 years of related experience.
• RN - Registered Nurse - State Licensure required.
• Knowledge of utilization management processes preferred.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible work schedules including remote options.