Part-time Clinical Review Clinician - Appeals

Summary:

• Work Mode: 100% Remote – Nationally sourced
• Duration: 5 months, possible extension
• This is a part-time role with 20-hour work weeks. The schedule must be consistent once agreed upon, with options to work 5 hours per day for 5 days a week or 3 days a week to reach 20 hours.

Responsibilities:

• Prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing the appeal basis.
• 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 appeal requests.
• Generate appropriate appeals resolution communication and reporting for members and providers in accordance with company policies, State, Federal, and NCQA standards.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeal 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:

• Education/Certification: Associate in nursing, Bachelor’s in nursing or higher preferred.
• Licensure: RN, LPN required; LVN preferred.
• Must have Medicare knowledge, InterQual or Milliman experience, and clinical reviews for Utilization Management or Appeals.
• Disqualifiers include not having a valid/active RN/LPN license.

Preferred Skills:

• Medicare Appeals Experience.