Clinical Review Clinician - Appeals

1 Utilization Management or Appeals review background (1 plus year) 2 Medicare NCD/LCD and InterQual/Milliman Software (1 plus year) 3 Retrospective claims clinical reviews (1 plus year) Purpose of this job: We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers.

Location: 100% Remote Nationally sourced. However, would like 1 candidate in AZ

Shift: 8-5 EST or CST time zone-weekend rotation required.

Duration: 6+ months, possible extension

Purpose of this job: We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. These reviews determine if members can/did receive medically necessary services.
Department is launching a BPO with expected team impacts. Resignations have come in and the need for this request is to mitigate staff leaving until BPO is up and running.

Description: Job Profile Summary: Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on. Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations. Work closely with the MD team to make final decisions on cases. The clinical team works closely with their supervisors and senior clinicians on the team for support. Team does have group chats on Teams for routine questions.

Team works closely together along with the coordinator team who owns end to end process on cases. Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.

Candidate Requirements
Education/Certification	Required			Preferred: : Associate in nursing, Bachelor s in nursing or higher.
Licensure	Required: RN, LPN			Preferred: LVN
Years of experience required Disqualifiers Best vs. average Performance indicators		Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals Nice to haves: Medicare Appeals Experience Disqualifiers: Not having a valid/active RN/LPN license Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases Best vs. average: Productivity expectations are set based on platform.
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Utilization Management or Appeals review background (1 plus year)
		2	Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
		3	Retrospective claims clinical reviews (1 plus year)