Clinical Review Clinician - Appeals

Position Title : Clinical Review Clinician - Appeals

Work Location : Remote - Ohio (Columbus area preferred)

Assignment Duration : 6 months

Work Schedule : 8a-5p (NO OT required)

Work Arrangement : Remote

Position Summary :

• Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system).
• Behavior and accountability and ability to pivot when new priorities come up.
• Emails and Team chats to ensure communication is reached and assistance is available, if needed.

Candidate Requirements :

Education / Certification

Licensure

Nice to Haves :

Disqualifiers :

Performance Indicators (Metrics) :

Candidate Requirements

Education / Certification

Required : LPN Minimum

Preferred : RN-Not required

Licensure

Required : LPN minimum

Preferred :

Must haves : (SEE NUMBERED SECTION BELOW)

Nice to haves :

Direct patient care experience

Longevity at positions

Writing appeal or authorization outcome letters.

experience with Trucare and / or Amisys systems is greatly valued.

Disqualifiers : Not possessing the must haves

Performance indicators : (Metrics :

Best vs. average :

Experience with Utilization Review / Management 2 yrs

Reviews relevant information within denied authorization / prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case.

Review medical code data and records to determine whether a denial is

warranted.

Utilizing multiple appeals / claims systems to conduct medical reviews.

Comfortable with Microsoft office programs and utilizing systems to input medical criteria.