Appeals Clinical Consultant

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Act as a crucial clinical resource for various elements of Appeals & Grievances operations.

• Assist Analyst teams in enhancing their understanding of medical terminology and provider care plans.

• Evaluate and analyze cases while consulting with Analysts concerning physician reviews.

• Identify complex members and work with Analysts to direct them to case management or disease management initiatives.

• Review appeal and grievance patterns and assist leadership in crafting communications for internal stakeholders.

• Consult with Analysts and MD reviewers on intricate appeals and grievances.

• Support Analysts in preparing cases and serve as a voting member on cross-functional Appeals Committees.

• Offer clinical insights within the scope of practice for appeal determinations.

• Aid in new-hire training focused on the clinical aspects of Appeals & Grievances tasks.

• Execute additional duties and projects as assigned.

⛳️ Requirements

• Comprehension of Appeals & Grievances processes, especially within the managed care sector.

• Emphasis on Commercial plans and Medicaid.

• Clinical expertise and capacity to grasp medical terminology and provider care plans.

• Proficiency in analyzing and evaluating appeals and grievances.

• Capability to work autonomously and cooperatively in a team setting.

• Talent for identifying complex members and directing them to case management or disease management programs.

• Skill in evaluating appeal and grievance trends.

• Ability to provide clinical insights within the scope of practice.

• Credentials and experience suitable for the position, as assessed by the employer.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Retirement plan options.

• Paid time off.

• Employer-funded life and disability insurance with additional buy-up coverage alternatives.

• Tuition assistance program.

• Well-being benefits.

• Comprehensive benefits package to support professional development, individual and family health, and financial well-being.

• Eligibility for variable pay.