Authorization Management Clinical Reviewer – Appeals and Denials

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

📋 Description

• Evaluate acute and post-acute authorization requests and medical records to assess medical necessity according to established clinical guidelines.

• Oversee medical necessity denials from the initial notification until final resolution.

• Utilize acute-care clinical expertise, payer requirements, and medical necessity criteria to identify suitable resolution paths.

• Ensure prompt follow-up and escalation of denials.

• Analyze clinical documentation, payer policies, and medical necessity criteria to formulate comprehensive, evidence-based appeals within set deadlines.

• Detect denial trends, root causes, and opportunities for process improvements to minimize preventable denials and enhance reimbursement outcomes.

• Work collaboratively with physician advisors, utilization review nurses, hospital stakeholders, physicians, healthcare providers, and both internal and external stakeholders.

• Establish appropriate appeal strategies, including peer-to-peer reviews, reconsiderations, and formal appeals.

• Assess acute and post-acute authorizations using InterQual guidelines.

• Partner with case managers, physicians, and medical directors to ensure suitable levels of care.

• Engage in team meetings, educational activities, and interrater reliability testing.

• Ensure adherence to federal, state, and accreditation standards.

• Leverage healthcare-system resources to effectively assist physicians and patients.

• Perform additional job responsibilities as assigned.

⛳️ Requirements

• Strong background in acute-care clinical settings with the capability to apply evidence-based guidelines.

• Proficient in technology solutions, including Microsoft Office and utilization management support tools.

• Familiarity with CarePort Care Management is preferred.

• Licensed RN, with the potential to obtain other required clinical state licenses.

• Bachelor's Degree or equivalent work experience.

• Active RN License.

• Minimum of 4-6 years of relevant work experience.

• At least 3 years of experience in denial management within an acute hospital environment, including the development and submission of medical necessity appeals.

• 2 years of clinical acute nursing experience.

• 1-2 years of hospital-based utilization management experience.

• Experience with managed care and CMS standards is preferred.

• Experience collaborating with physician advisors on peer-to-peer reviews, reconsiderations, and formal appeals is preferred.

• Knowledge of UM/CM regarding ICD, CPT, DRGs, and hospital revenue cycle workflows is preferred.

• Proficient in the use of window-based computer programs is preferred.

• Excellent verbal, written, and interpersonal communication skills are preferred.

• Critical thinking, creative problem-solving, organizational, and planning skills are preferred.

• Experience with InterQual guidelines for acute-care and/or other clinical decision support tools, particularly in utilization management and prior authorization processes, is preferred.

• Experience with CarePort Care Management is preferred.

• Willingness to work additional or irregular hours as required.

• Must adhere to applicable security policies and procedures to protect company and client information.

• Must be able to sit and view a computer screen for prolonged periods.

• Applicants for positions based in the U.S. must be legally authorized to work in the United States.

🏝️ Benefits

• Comprehensive medical benefits including Rx, dental, and vision coverage.

• Mental health support through Employee Assistance Program (EAP).

• Generous paid time off policy.

• 13 paid holidays each year.

• 100% vested 401(K) retirement plans.

• Educational assistance up to $2500 annually.

• Eligibility for full-time teammate benefits.