Clinical Review Clinician – Appeals

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Conducts clinical evaluations necessary for resolving and processing appeals by examining medical records and clinical data to assess the medical necessity of services in alignment with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

• Prepares case assessments for Medical Directors by investigating the appeal, reviewing relevant criteria, and evaluating the grounds for the appeal.

• Guarantees prompt review, processing, and response to appeals in compliance with State, Federal, and NCQA standards.

• Engages with members, providers, facilities, and various departments concerning appeal requests.

• Produces suitable appeals resolution communications and reports for members and providers, adhering to company policies as well as State, Federal, and NCQA standards.

• Collaborates with leadership to enhance the consistency, efficiency, and appropriateness of responses to all appeal requests.

• Partners with interdisciplinary teams to refine clinical appeals processes and procedures to avert recurrences based on industry best practices.

• Performs additional duties as assigned.

• Adheres to all policies and standards.

⛳️ Requirements

• Graduate from an Accredited School of Nursing or possess a Master's degree in a related Behavioral/Counseling field.

• A minimum of 2 to 4 years of relevant experience.

• Preferred: 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health, and/or Managed Care environments.

• Preferred: Direct work experience with clinical data, clinical reviews, and specifically the APPEALS processes and procedures.

• Preferred: Knowledge of NCQA, Medicare, and Medicaid regulations.

• Preferred: Understanding of Utilization Management principles and processes.

• Strong communication, attention to detail, organizational, and time management skills.

• Proficient in utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g., instant messaging, email, video conferencing, digital phone).

• Comfortable using video conferencing platforms (ZOOM Meeting, MS Teams).

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.