Clinical Review Clinician – Appeals

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

📋 Description

• Conduct clinical reviews necessary for the resolution and processing of appeals.

• Analyze medical records and clinical data to assess medical necessity in accordance with policies, guidelines, and NCQA standards.

• Prepare case reviews for Medical Directors by investigating appeals, evaluating criteria, and analyzing the grounds for appeals.

• Ensure that reviews, processing, and responses to appeals are completed promptly, adhering to State, Federal, and NCQA standards.

• Communicate effectively with members, providers, facilities, and other departments regarding appeal requests.

• Create appeals resolution communications and reports for both members and providers.

• Collaborate with leadership to enhance the consistency, efficiency, and appropriateness of appeal responses.

• Partner with cross-departmental teams to refine clinical appeals processes and prevent future occurrences.

• Perform additional assigned duties while complying with established policies and standards.

⛳️ Requirements

• A degree from an accredited school of nursing or a Master’s degree in Behavioral Health or Social Work.

• 2–4 years of relevant experience.

• At least 2 years of acute care experience.

• Experience in utilization management or appeals.

• Familiarity with MCG/InterQual criteria.

• Understanding of NYS Medicaid, Medicare, and Marketplace appeal regulations.

• RN - Registered Nurse - State Licensure and/or Compact State Licensure is required, or LCSW, LMHC, LPC, LMFT, Licensed Psychologist, or an equivalent listed license is required.

• Knowledge of NCQA, Medicare, and Medicaid regulations is preferred.

• Familiarity with utilization management processes is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in the overall compensation package.

• An equal opportunity employer dedicated to diversity.