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The Clinical Reviewer Specialist role involves conducting clinical reviews to process appeals and ensure compliance with NCQA standards. Candidates should have 1-3 years of experience in utilization management and hold a US Registered Nurse license. Strong analytical and communication skills are essential for success in this position.
Job Responsibility:
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
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 providers, facilities and other departments regarding appeal 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 appeal requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards
Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals
Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation
Prepare case recommendations for medical review as necessary
Requirements:
1-3 years of experience in processing appeals or utilization management
US Registered Nurse (USRN)
Knowledge of utilization management process
Knowledge of NCQA, Medicaid regulations
Good communication (Demonstrate strong reading comprehension and writing skills)
Able to work independently, strong analytic skills