Clinical Review Clinician - Appeals

Job Title: Clinical Review Clinician - Appeals
Duration: 06 months (Possibility for extension or conversion)
Shift Schedule: 8-5 EST or CST time zone-weekend rotation required.
Location: Remote- Nationally sourced. However, would like 1 candidate in AZ

Responsibilities:
Staff will work when there are members of the supervisor/leadership on.
Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations.
Work closely with the MD team to make final decisions on cases.
The clinical team works closely with their supervisors and senior clinicians on the team for support.
Team does have group chats on Teams for routine questions.
Team works closely together along with the coordinator team who owns end to end process on cases.
Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.
Candidate Requirements Education/Certification Required Preferred: : Associate in nursing, Bachelor's in nursing or higher. Licensure Required: RN, LPN Preferred: LVN

• Years of experience required
• Disqualifiers
• Best vs. average
• Performance indicators

Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals

Nice to haves: Medicare Appeals Experience

Disqualifiers: Not having a valid/active RN/LPN license

Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases

Best vs. average: Productivity expectations are set based on platform.

• Top 3 must-have hard skills
• Level of experience with each
• Stack-ranked by importance
• Candidate Review & Selection

1 Utilization Management or Appeals review background (1 plus year) 2 Medicare NCD/LCD and InterQual/Milliman Software (1 plus year) 3 Retrospective claims clinical reviews (1 plus year)