Clinical Review Clinician (Appeals)

Responsibilities:

• 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 appeal 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 for the member and provider in accordance with company policies, State, Federal, and NCQA standards.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeals requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Minimum 2 years of related experience.
• State Licensure required for one of the following: LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist.
• For Health Net of California: RN license required.

Preferred Skills:

• Knowledge of NCQA, Medicare, and Medicaid regulations.
• Knowledge of utilization management processes.