Clinical Reviewer Specialist

The Clinical Reviewer Specialist plays a vital role in processing appeals by conducting thorough clinical reviews of medical records and data. This position requires a strong understanding of medical necessity and utilization management, along with excellent communication skills. Candidates should have at least 1-3 years of relevant experience and hold a Registered Nurse license. The role involves collaboration with various departments to enhance the appeals process and ensure compliance with NCQA standards. 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. Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review.