Clinical Review Clinician - Appeals

Immediate need for a talented Clinical Review Clinician - Appeals . This is a 03+ Months Contract opportunity with long-term potential and is located in AZ(Remote) .

Please review the job description below and contact me ASAP if you are interested.

Job ID : 24-31702

Pay Range : $35 - $40 / hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Note-As a part of our hiring process, along with an option to directly connect with a Recruiter or apply online, we now offer a texting option to enhance your candidate experience.

Click the link below which contains the job description and a few basic questions that will help you ensure this is a good fit and expedite the shortlisting process.

Key Responsibilities :

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
• Knowledge of NCQA, Medicare and Medicaid
• Utilization management processes preferred.
• License / Certification :
• LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or
• RN - Registered Nurse - State Licensure and / or Compact State Licensure required.
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicates with members, providers, facilities, and other departments regarding appeals requests.
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Complies with all policies and standards.

Key Requirements and Technology Experience :

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 4 years of related experience.
• Knowledge of NCQA,
• Previous Appeals experience.
• Exp with clinical reviews.
• Medicare and Medicaid highly preferred.

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions.

If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.