Clinical Reviewer Specialist

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. \n\nRoles and Responsibilities:\n\nPrepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. \n\nEnsures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.\n\nCommunicates with providers, facilities and other departments regarding appeal requests. \n\nGenerates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards. \n\nWorks with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests. \n\nPartners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices. \n\nIndividuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review. \n\nUses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards. \n\nMaintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals. \n\nReview claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.\n\nPrepare case recommendations for medical review as necessary. \n\n1-3 years of experience in processing appeals or utilization management. \n\nRN - Registered Nurse - State required Licensure and/or Compact State Licensure\n\nKnowledge of utilization management process \n\nKnowledge of NCQA, Medicaid regulations\n\nGood communication (Demonstrate strong reading comprehension and writing skills)\n\nAble to work independently, strong analytic skills\n\nRequired shift timings - US daytime\n